Arizona Rural Health Workforce Trend Analysis. A report prepared for the

Transcription

1 Arizona Rural Health Workforce Trend Analysis A report prepared for the Howard J. Eng, Joe Tabor, Alison Hughes Arizona Rural Health Office Mel and Enid Zuckerman College of Public Health The University of Arizona April 2011

2 ACKNOWLEDGEMENTS The Arizona Rural Health Workforce Trend Analysis is produced by the Arizona Rural Health Office (RHO), The University of Arizona Mel and Enid Zuckerman College of Public Health and funded by the Arizona Area Health Education Centers Program (AzAHEC). The authors would like to the thank the following for their contributions to the publication: Gary Hart for his assistance; Renee Fullerton and Sharon Van Shiver for formatting the report; Joyce Hospodar for her editing; and Patricia Tarango, Hal Wand, Arizona Department of Health Services, Arizona Medical Board of Examiners, Arizona Board of Osteopathic Medicine, American Medical Association, Arizona State Board of Nursing, Arizona Board of Dental Examiners, and Arizona State Board of Pharmacy for providing the health professional data.

3 TABLE OF CONTENTS Executive Summary 1. Introduction 1-1 Arizona Health Care Workforce Comparisons 1-1 Arizona Health Workforce Profiles Arizona Characteristics 2-1 Population and Geographic Characteristics 2-1 Arizona Population Trends 2-1 Rural and Urban Definitions 2-2 County Comparisons 2-4 Rural Health Characteristics Physicians 3-1 Arizona Physicians 3-1 Allopathic Physicians 3-2 Osteopathic Physicians 3-2 Primary Care Physicians 3-3 Specialist Physicians 3-6 Obstetrics/Gynecology Physicians 3-7 Psychiatric Physicians 3-9 Satisfying Future Physician Demand 3-11 Physician Practice Profile 3-11 Summary Physician Assistants 4-1 Summary Nurses 5-1 Registered Nurses 5-1 Certified Registered Nurse Anesthetists 5-2 Nurse Practitioners 5-3 Certified Nurse Midwives 5-4 Licensed Practical Nurses 5-5 Certified Nurse Assistants 5-6 Nursing Practice Profile 5-8 Summary 5-8

4 6. Dentists 6-1 Arizona Dentists 6-1 General Dentists 6-2 Dentist Specialists 6-3 Dentist Practice Profile 6-4 Dental Shortage Areas 6-4 Summary Pharmacists and Pharmacy Technicians 7-1 Pharmacists 7-1 Pharmacy Technicians 7-2 Pharmacists and Pharmacy Technician Practice Profiles 7-3 Summary Emergency Medical Technicians 8-1 Summary Conclusions and Recommendations Appendices 10-1 A. List of Tables 10-1 B. List of Figures 10-7 C. List of Maps D. Data Sources and Methods E. Arizona, Counties, and RUCAs Health Workforce Comparisons 10-25

5 EXECUTIVE SUMMARY Trends in the numbers of licensed health care professionals relative to the population in Arizona from 2002 to 2006 have generally been stable or have increased. The rural areas have fewer licensed professionals relative to the population than the urban areas. The workforce trends for many professions show that the inequalities between urban and rural areas are increasing, especially for the most rural areas of Arizona. There were statewide and urban increases in the numbers of all the health care professionals studied. The health professions examined were allopathic and osteopathic physicians (primary care physicians, specialists, obstetrics-gynecologists, and psychiatrists), physician assistants, registered nurses, nurse practitioners, certified nurse midwives, nurse anesthetists, licensed practical nurses, certified nurse assistants, dentists (generalists and specialists), pharmacists, pharmacy technicians, and emergency medical technicians. The analysis was conducted for the state, by counties, and by four statewide ruralness categories (rural-urban commuting areas). The growth trends for number of licensed professionals relative to the population were greater for pharmacy technicians (68%), certified registered nurse anesthetists (50%), physician assistants (29%), specialist dentists (25%), pharmacists (23%), and nurse practitioners (21%) from 2002 to During the same period, the number of obstetricsgynecologists relative to the population they serve decreased 3 percent. This study used Arizona professional licensing board data to examine trends in actively licensed professionals that reported an Arizona mailing address. The yearly number of licensed professionals in a county or ruralness category should not be used to directly represent the availability or access to health care because some of the licensed professional do not work full time or do not provide direct patient care (e.g., administrative roles). Also, some professionals working in Arizona are not included in the analysis because they were licensed elsewhere through reciprocal agreements between states or for federal employees. Arizona will face greater competition with other states in recruiting and retaining health professionals due to expected increase in demand for services through implementation of the Patient Protection and Affordable Care Act. Maintaining the current number of health professionals relative to the population will be especially difficult since the large proportion of professionals from the baby boomer generation are starting to retire.

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7 SECTION 1: INTRODUCTION Access to health care services is a top priority for policy makers at federal, state, and local levels. How the health care workforce is distributed impacts access to care, particularly in rural and remote areas of the state. To that end, the Arizona Area Health Education Centers Program (AzAHEC) invested in this study that examined the extent to which the state s health care workforce distribution has changed over time. The AzAHEC asked researchers at the Rural Health Office in the Mel and Enid Zuckerman College of Public Health to study workforce distribution trends and to offer conclusions and recommendations that might impact AzAHEC and the State of Arizona strategic approaches. This report provides state, rural and urban health care provider distribution comparisons and multi-year trends that can be used to review policies and programmatic practices. Congressional passage of the Patient Protection and Affordable Care Act of 2010 (PPACA) brings with it a measure of health reform in the country that will rapidly increase the demand for health care as well as training programs in health information technology adoption. By 2014 when the Act moves fully into effect, Arizona s health workforce will experience a higher demand for patient care, and by 2014 pressure to adopt electronic health records, and electronic health record exchange systems will add stress to the unprepared. In addition to increased demand for health care services, the retirement of baby boomers will further stress the health care system. For example, 51 percent of Arizona s practicing physicians are over 50 years old. The rates of retirement will be different between health care professions and specialties. Effectively replacing this retiring workforce will require a nuanced approach resulting from evidence informed action. Workforce studies will be continuously needed to examine the effects of the PPACA on access to health care in rural and remote areas of the state. Examples include rural health workforce distribution, the impact of health facility expansions (e.g., Arizona s 16 Federal Qualified Health Centers and their satellites, rural health clinics, and small hospitals) on rural health workforce, the effects of the aging of rural populations on the demand of health services, the impact of the aging health workforce on the delivery of rural health care, and the effects of health technology on workforce needs. The health professions examined in this report were physicians (primary care, specialist, obstetricsgynecologist, and psychiatrist), physician assistants, nurses (registered nurses, nurse practitioners, certified nurse midwives, nurse anesthetists, licensed practical nurses, and certified nurse assistants), dentists (general and specialist), pharmacists, pharmacy technicians, and emergency medical technicians. In the report, workforce data is presented from 2002 to 2006 for each health profession and for some professions 2007 data is also included. State, rural and urban workforce trend comparisons are included in the report. The results from other health care workforce studies are presented to add context to the data and information presented. Care needs to be exercised by users of this report when comparing estimates of workforce coverage in this study with those from different studies due to issues related to differences in data sources and quality, classification of professions, licensing requirements, estimates of full-time equivalent work (FTE) from number of active licenses, and productivity of workers. Results from other studies are presented in this report to provide additional information, for example the paragraph and table below presents a national comparison between states. The national comparison is followed by results from this study and is based on professional licensing board data. Arizona Health Care Workforce Comparisons: In Arizona, the number of health practitioners increased between the 2000 and 2004 HRSA funded state health workforce profiles. 1-2 Table 1-1 shows the changes for nine health professions. There were increases in the number of health practitioners per 100,000 population for physician assistants, nurse practitioners, dentists, pharmacists, and psychologists and a decrease in the practitioner to population ratio for registered nurses, certified nurse midwives, and licensed practical nurses. Arizona s national health professional rankings fell between the two time periods for physicians, certified nurse midwives, registered nurses, and licensed practical nurses, while for physician assistants, nurse practitioners, dentists, pharmacists, and psychologists had improved its national rankings. 1-1

8 Table 1.1. Arizona Health Workforce Changes: 2000 and 2004 HRSA State Health Workforce Profile Publications Health Professional Data Year Arizona #/100,000 National # / 100,000 National Ranking Physicians / /50 Physician Assistants Nurse Practitioners Certified Nurse Midwives Registered Nurses Licensed Practical Nurses Dentists Pharmacists Psychologists Source: National Center for Health Force Analysis /50 10/50 30/50 21/50 17/50 41/50 37/50 45/50 27/50 46/50 41/50 22/50 49/50 46/50 27/50 21/50 Arizona Health Workforce Profile: By 2006, registered nurses (RNs) were the largest health care professional group in the state. The 51,122 active licenses in 2006 provided Arizona 829 RNs per 100,000 population, a standard metric for service coverage in health care workforce analysis. Certified nurse assistants (CNAs) was the next largest group of professionals where 20,360 active licenses in 2006 provided Arizona with 330 CNAs per 100,000 (Table 1.2). Of the 17 health professionals examined, RNs showed the greatest increase in numbers from 2002 to 2006 (+6,616), but only added 12 RNs per 100,000 to Arizona s rapidly growing population. Pharmacy technicians were the fastest growing health profession. During , their numbers grew by 81% (+2,721) and increased their coverage by 40 per 100,000 population. The coverage of OB/GYN physicians dropped by 2 per 100,000. The report is divided into seven major sections: Arizona Characteristics, Physicians, Physician Assistants, Nurses, Dentists, Pharmacists and Pharmacy Technicians, and Emergency Medical Technicians. For the rural and urban health workforce distribution and trend comparisons, two geographic classification methods were used to measure rurality. One method aggregated data for each county into three state wide categories: urban counties, ruralurban counties, and rural-rural counties. The other method, rural-urban commuting areas (RUCA) classification, aggregated data for each postal zip code into four state wide categories: urban areas, large rural town areas, small town areas, isolated small town areas (Appendix D.2). If available, national health professional ranking and state health professional practice profiles are reported. 1.1 References 1. Bureau of Health Professions, National Center for Health Workforce Information & Analysis, Health Resources and Services Administration. (2000). HRSA State Health Workforce Profiles: Arizona. pp The New York Center for Health Workforce Studies. (2006) The United States Health Workforce Profile. pp

9 Table 1.2. Arizona Health Workforce Profile for Selected Professionals: 2006 Health Profession Number in Net Chg from Percent Chg Number Number Chg to 2006 (2002 to 2006) /100,000 (2002 to 2006) Physicians 13,429 1,826 16% /100,000 Primary Care Physicians 4, % 72 +3/100,000 Specialist Physicians 9,005 1,146 15% /100,000 OB/GYN Physicians % 60* -2/100,000 Psychiatrist Physicians % 11 No Change Physician Assistants 1, % 22 +5/100,000 Registered Nurses 51,122 6,616 15% /100,000 Nurse Practitioners 2, % 34 +6/100,000 Certified Nurse Midwives % 12** No Change Licensed Practical Nurses 8,754 1,751 25% /100,000 Certified Nurse Assistants 20,360 2,038 11% 330-6/100,000 Dentists 3, % 54 +7/100,000 General Dentists 2, % 44 +4/100,000 Specialist Dentists % 10 +2/100,000 Pharmacists 4,965 1,347 37% /100,000 Pharmacy Technicians 6, /100,000 Emergency Med. Tech. 15,032 3,049 25% /100,000 Sources: Arizona Department of Health Services and Health Professional Board s Practitioner Data Files. * OB/GYN Physicians per 100,000 child bearing age women (15-44 y/o). **Midwives per 100,000 women of child bearing age (15-44 Change for only 2004 to 2006; pharmacy technicians were not certified by the State Board of Pharmacy before Population estimates provided by 1-3

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11 SECTION 2: ARIZONA CHARACTERISTICS 2.1 General Population and Geographic Characteristics According to the U.S. Census Bureau, Arizona is one of the fastest growing states in the nation and experienced a 17 percent increase in population from 2000 to 2006 (6,165,689 residents). Arizona s 114,000 square miles makes it the 6 th largest state, exceeded in area by Alaska, Texas, California, Montana, and New Mexico. 1 Although most of its surface area is frontier a and rural, the majority of the population resides in urban centers such as Phoenix (Maricopa County) and Tucson (Pima County) (Map 2.1). Arizona is one of four U.S.-Mexico border states with 4 of its 15 counties sharing a southern border with Mexico. Arizona is bordered to the north by Nevada and Utah, to the east by New Mexico, and to the west by California. The state s culture and history are replete with influences assimilated from the Spanish Empire to Mexican, Central and South American immigrants. At the same time, the state is home to 22 federally recognized American Indian tribal lands b, including a portion of the Navajo nation, the largest on-reservation population in the United States. Economically, the state represents a diverse mixture of professions and incomes as retirees, military, and high tech industry leaders reside in communities with teachers and farm laborers. Land ownership in the state is 17.6% private, 27.6% Indian reservation, 39.5% Federal, and 15.3% state and county lands (Map 2.2). Arizona Population Trends: There are demographic differences between Arizona and the United States. In 2006, men slightly outnumbered women in Arizona, but nationally there were slightly more women than men. There were more Arizonans aged 0-17, 25-34, and 65 years and older than the national percentages (Figure 2.1). In 2006, the largest age group in Arizona was under 18 years (26.4%) and 12.8 percent of the population was 65 years or older. During 2000 to 2006, those 65 years and older declined slightly (13.1% in 2000 to 12.8% in 2006) while those and increased (12.2% and 8.6% respectively in 2000, to 12.8% and 10.0% in 2006) (Figure 2.2). Map 2.1. Map of Arizona counties based on surface-area and a cartogram based on population. In 2006, there were noticeable differences in racea. Frontier areas are the most isolated, rural settled places along the rural-urban continuum, with residents far from health care, schools, grocery stores, and other necessities. b. With the inclusion of sacred areas of Zuni tribal land there are 22 federally recognized American Indian tribal lands in Arizona. 2-1

12 ethnicity between the U.S. and Arizona (Figure 2.3). Arizona had lower proportion of Whites, Blacks, and Asian-Pacific Islanders than the U.S. percentages, but a much higher proportion of Hispanics and American Indians. Arizona had almost twice the proportion of Hispanics and over five times the proportion of American Indian than the U.S. The Hispanic (29.2%) and American Indian (4.2%) populations are the two largest minority populations in the state. Between 2000 and 2006, the percent of Whites decreased 4.1% and American Indians decreased 0.8%, while Hispanic (3.9%), Black (0.1%) and Asian-Pacific Islanders (0.5%) populations increased (Figure 2.4). The structure of employment in the Arizona economy was somewhat different from the rest of the nation. In 2000, the largest employment sector in Arizona was in the service industries, which provided 82.4 percent of all employment a figure that outpaced the U.S. total of 77.3 percent. 2 In Arizona, the three goods-producing industries (mining, construction, and manufacturing), employed lower percentage of workers (17.6%) than the U.S. as a whole (22.7%). The largest difference in employment distribution was in the manufacturing sector, where Arizona (9.7%) trailed the U.S. (15.4%). 2 Arizona s median household income of $40,558 trailed the national median of $41,994 in 2000 and in 2006 ($47,265 vs. $50,233). During this 7 year period Arizona s unemployment rate increased slightly from 4.0 percent in 2000 to 4.1 percent in 2006 and its population that was at or below the Federal Poverty Level (FPL) increased from 13.6% to 13.9%. 2.2 Rural Geographies and Health Characteristics Map 2.2. Populations of Cities and Towns by Arizona Counties and Land Ownership Figure 2.1. Age Group Distribution for U.S. and Arizona: 2006 Figure 2.2. Age Group Distribution for Arizona: 2000 and 2006 Rural and Urban Definitions There are distinct differences between urban and rural areas. For instance, there are generally fewer health resources available in rural areas than urban areas. There is no single, universally preferred definition of rural, nor can a single rural definition serve all policy issues. The State of Arizona has defined rural as (i) a county with a population less than 400,000 persons according to the most recent United States decennial census, and (ii) a census county division with less than 50,000 persons in a county with a population of 400,000 or more persons according to the most recent United States decennial census. 3 Nationally, there are several definitions of rural used. Rural definitions include those defined by: The U.S. Census Bureau bases rurality on a combination of population density, relationship cities, and population size. The Office of Management and Budget (OMB) classifies counties on the basis of their population size and integration with large cities. 2-2

13 Figure 2.3. Race/Ethnicity Distribution for U.S. and Arizona: 2006 Percent of Population Figure 2.4. Race/Ethnicity Distribution for Arizona: 2000 and 2006 Percent of Population Goldsmith and Associates has modified the OMB s definition to include parts of large metropolitan counties that are small town or open-county and without easy geographical access to central areas. The U.S. Department of Agriculture bases rurality on a rural typology that provides a way to identify groups of U.S. nonmetropolitan counties sharing important economic and policy traits. The U.S. Administration on Aging combines the identification of urbanized areas as defined by the U.S. Census Bureau and zip code postal boundaries to classify all zip code areas as either urban or rural. University of Washington Rural Urban Commuting Areas (RUCAs) defines degrees of rural and urban by their proximity to urban areas and the portion of the population that commute from rural to urban areas. 4-6 In addition, the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), also uses the definition of frontier for federal funding purposes. c Frontier differs from rural in that it may apply to much more sparsely populated, isolated areas. Funding availability for rural areas is highly dependent on which definition is used. Some rural funding sources include: Rural Health Outreach Grant Program that creates models of outreach and health care delivery services in rural areas, Rural Health Network Development Grant Program that develops an integrated health care network in rural communities, Medicare Rural Hospital Flexibility Grant Program that helps to stabilize and improve access to America s smallest and most vulnerable rural hospitals, and Small Rural Hospital Improvement Grant program that supports small rural hospitals with the implementation of projects involving the prospective payment system, value based purchasing, accountable care organizations, and bundled payments. 7 The rural definition used is important and can determine whether or not a community is designated as a medically underserved area (MUA), medically underserved population (MUP), and/or health professional shortage area (HPSA). These designations affect the placement of National Health Service Corp health personnel and J-1 Visa physicians, and the rural reimbursement for nurse practitioners, physician assistants and nurse midwives for rural health clinics. This report used two geographic classification methods to identify rural areas, an ad hoc method that aggregated data for each county into three state wide categories that followed the definition used in the Arizona Rural Health Plan , 8 and the rural-urban commuting areas (RUCA) classifications that aggregated data for each postal zip code into four state wide categories. The county based classification used political units to differentiate rurality and provides grouping to assess state and county based polices. The RUCAs provide a higher resolution than counties to differentiate levels of rurality in the state (Appendix D.2). The three county based categories are illustrated in Map 2.3 and the four zip code based categories are illustrated in Map 2.4. c. HRSA is expected to introduce a new definition of frontier in the Federal Register in summer,

14 County Comparisons: The 2006 population demographics for the urban, rural-urban, and rural-rural counties are summarized below. Arizona s two urban counties, Maricopa and Pima, accounted for 76.5 percent of the state s population. Demographically, they were very similar: males slightly outnumbered females and, children 17 years of age or younger comprised 29.3 percent of the population, and seniors aged 65 or older accounted for 11.8 percent. The population consisted of 30.5 percent Hispanics, 1.7 percent American Indians, 3.7 percent African Americans / Black, and 2.8 percent Asian Americans. The 2006 unemployment in Maricopa and Pima Counties were at 3.5 percent and 4.0 percent, respectively. Coconino and Yuma are Arizona s Rural-Urban counties comprising 5.1 percent of the state population. During 2000 to 2006, Yuma County s population increased 17.2 percent, more than two times Coconino s growth (7.4%). The gender breakdown for Coconino and Yuma Counties was almost evenly distributed between males and females. Children 17 years of age and younger comprissed 31.5 percent of the population. The population of these two Rural-Urban counties comprised 38.4 percent Hispanic and 11.9 percent American Indian. Yuma County differed from Coconino in one respect: in 2006, Yuma County had the highest unemployment rate in the state at 14.8 percent. The remaining 11 counties are designated Rural- Rural. From 2000 to 2006, these counties experienced an overall growth of 21.4 percent. Like other counties, the gender breakdown was nearly equal. The Mexican border counties Cochise (31.6 %) and Santa Cruz (80.6%) had the highest proportion of Hispanic s among the 11 Rural-Rural counties. American Indian reservations (e.g., Navajo, Hopi, Apache, and Zuni) occupy more than half of the northeastern counties of Apache and Navajo. The southwestern counties of Santa Cruz and Yuma that border Mexico consistently have the higher than average state unemployment rates. Rural Health Characteristics Rural areas frequently pose different and, in some instances, greater challenges than urban areas in addressing a number of health care issues. There are rural-urban disparities in health conditions associated with particular preventable or chronic diseases and disparities in infrastructure or professional capacity to address health needs. There Map 2.3. Arizona s Urban, Rural-Urban, and Rural-Rural Counties Map 2.4. Populations of Cities and Towns by RUCA Zip Code Geography is ample evidence that some important rural-urban health disparities exist with respect to, for example, shortages of primary care and specialist physicians, shortages of specialized mental health providers and oral health providers. Rural Arizonans face a unique combination of factors that create disparities in health status and well-being when compared to urban Arizonans. Conditions, such as, economic factors, cultural and social differences, education limitations, geographic isolation, lack of transportation systems, lack of access to specialty 2-4

15 services, lack of health insurance, lack of adequate support to maintain quality of medical care, and limited rural health infrastructure, present obstacles, both to rural residents seeking services as well as to the providers who deliver them. These conditions are often magnified on the U.S.-Mexico border as well as the American Indian communities and tribal reservations. Rural Arizonans are more likely to be older, poorer and less healthy than their urban counterparts. Health care issues of special concern in rural areas are cardiovascular disease, diabetes mellitus, mental health and mental disorders, oral health, tobacco use, substance abuse (including alcohol use), maternal/ child health, nutrition and obesity, cancer screening and treatment, older adult immunization rates, health workforce shortages, recruitment and retention of primary care providers, and access to insurance. The insurance problem is associated with a lower paid workforce reliant upon smaller employers who are less likely than larger employers to offer health insurance. The uninsured have limited access to timely and effective primary care that is deemed critical to avoiding hospitalization for ambulatory-care-sensitive conditions. The availability of timely emergency services (e.g., ambulance and trauma services) is also less available in rural Arizona than the urban areas. frequent movement of people between both countries and within the U.S. has increased the potential for international spread of diseases and has created difficulties identifying affected populations. High rates of hepatitis A and B and other intestinal infections, due to a lack of clean water and proper sewage disposal, are also a concern. The border region also has a higher prevalence rate of diabetes. Finally, communities along the border have some of the highest rates of poverty, unemployment, uninsured people, and lack of access to health care in the nation. The 22 federally recognized American Indian tribes b contribute to the rich cultural diversity of Arizona. Over 275,000 Native Americans (2006 Census estimates) contribute to Arizona s population. Reservations and tribal communities inhabit over a quarter of the State of Arizona. They are located mostly in rural and frontier areas (See Map 2.5). Tribes in Arizona face numerous logistic, economic, and health challenges. Compared to other population Map 2.5. Arizona s American Indian Tribes Of particular significance to rural Arizona is the consideration of the special characteristics of communities along the U.S.-Mexico border. The La Paz Agreement d defines the U.S.-Mexico border region as extending approximately 2,000 miles from the Pacific Ocean to the Gulf of Mexico, and approximately 62.5 miles (100 kilometers) from both sides of the border. Four of Arizona s fifteen counties Yuma, Pima, Santa Cruz, and Cochise create a 377 mile border including 80 miles of the Tohono O odham Reservation that are contiguous to Mexico. There are four American Indian tribes that reside in the four counties that are contiguous to the border. Of the 12 sister cities located on the U.S.-Mexico Border, three of them are in Arizona (Yuma/San Luis Rio Colorado, Nogales/Nogales, and Douglas/Agua Prieta). Residents living along the U.S.-Mexico Border experience greater rates of communicable diseases such as tuberculosis and vaccine preventable illnesses than people across the United States. The Source: Arizona Department of Transportation d. A 1983 Agreement on Cooperation for the Protection and Improvement of the Environment in the Border Area Border2012/docs/LaPazAgreement.pdf 2-5

16 groups, American Indians have a higher incidence of diabetes, heart disease, certain cancers, tuberculosis, substance abuse, obesity, and violence. A growing tribal demand for diabetes care has placed a heavy burden on the American Indian health care system. A lack of culturally competent care delivered by health care providers, inadequate funding for health care, and poor access to care compound the problems and make the solutions challenging to attain. While some tribes choose to take control of their health care systems through options like 638, e for most Indian people the health care they receive comes from a blend of Indian Health Service (IHS), state, local, and private providers. Seamless access to care is still lacking. 2.3 References 1. Gordon, R. J. (1987). Arizona Rural Health Provider Atlas, Rural Health Office, Department of Family and Community Medicine, University of Arizona College of Medicine. pp Eng, H. J., Resnick, C., Yordy, K., DuVal, M., Vogel, R., Brill, J., Paz-Ono, J., Parces, M., Voloudakis, M., Khandokar, I., Clarihew, B., and Jacobs, J. (2002). Health Care Coverage in Arizona: Full Assessment. pp , Appendices A-I. 3. A.R.S (2004). az.us/arizonarevisedstatues.asp. 4. Ricketts, T.C., Johnson-Webb, K.D., and Taylor P. (1998). Definition of Rural: A Handbook for Health Policy Makers and Researchers. pp Goldsmith, H.F., Puskin D.S., and Stiles D.J. (1993). Improving the Operational Definition of Rural Access for Federal Programs. pp California State Rural Health Association (2003) Testimony to the California Rural Health Policy Council on Federal Definition of Rural Based on Rural Urban Commuting Areas. Retrieved on September 3, 2003 on World Wide Web: advocate/2.6/definitionissues. html. 7. Health Resources and Services Administration Office of Rural Health Policy (2003). Program Summaries: Rural Health Outreach Grant Program, Rural Health Network Development Planning Grant Program, Medicare Rural Flexibility Hospital Grant Program, and Small Rural Hospital Improvement Grant. 8. Eng, H. J., Jacobs, J., and Peashock J. (2004) Arizona Rural Health Plan , pp e. 638 refers to an agreement which states that tribes can operate a facility under a P.L self-determination contract (Title I) or selfgovernance compact (Title III). Currently, there is one tribal nation in Arizona the Gila River Indian Community which operates a 638 facility, and the Navajo Nation is conducting three 638 pilot community sites. 2-6

17 SECTION 3: PHYSICIANS In 2006, there were 13,429 physicians with active Arizona licenses in the state. There are two types of physicians: allopathic and osteopathic. Both allopathic (MD) and osteopathic (DO) physicians provide preventive, primary, and chronic care. Osteopathic medicine differs from allopathic medicine by emphasizing the importance of normal body mechanics and manipulative methods of detecting and correcting faulty structure. 1 The physician data used was provided by the Arizona Department of Health Services (ADHS) physician datasets from 2002 to The origin of these data was from the Arizona Medical Board of Examiners (allopathic physicians) and Arizona Board of Osteopathic Medicine (osteopathic physicians). Allopathic physician data file from 2007 were also obtained from the Arizona Medical Board of Examiners and are included however 2002 and 2006 comparisons are use for both MD and DO data. Total Arizona Physicians: From 2002 to 2006, the number of physicians in the state increased 16 percent (+1,826). The two urban classified counties and 11 rural-rural classified counties increased at the rate of 16 percent, while the two rural-urban classified counties increased 15 percent. During the five years, Apache County s number of physicians decreased 24 percent. The largest increase in number of physicians occurred in Pinal County (31%). The New York Center for Health Workforce Studies reported that in 2004 Arizona was ranked 35th nationally by the ratio of number of physicians per 100,000 population. 2 Arizona had physicians per 100,000 population, while the U.S. had an average of per 100, This national study used data from the Health Resource File that was provided by the American Medical Association and the American Osteopathic Association. The physician counts comprised those MDs and DOs that provided nonfederal patient care. Residents and fellows were excluded. Analysis of the ADHS data for 2004 showed 222 physicians per 100,000 population in Arizona; this ratio slightly decreased to 218 per 100,000 in For all three county ruralness categories, the physicianpopulation ratios increased during the five years: urban counties increased from 239 to 244 per 100,000, rural-urban counties increase from 166 to 175, and rural-rural counties increased from 118 to 120. The 2006 county rankings of physicianpopulation ratio are presented in Map 3.1. The three counties with the largest physicianpopulation ratios in 2006 were Pima (289 per 100,000), Coconino (235), and Maricopa (233) counties, while the smallest were Apache (49 per 100,000), Pinal (73) and Santa Cruz (81) counties. Figures 3.1 and 3.2 show Map 3.1. Physician- Population Ratios by AZ Counties for 2006 Source: ADHS Figure 3.1. Total Physicians (MD and DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.2. Total Physicians (MD and DO) per 100,000 Population Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. 3-1

18 the 2002 to 2006 trends of number and physicianpopulation ratios state wide and for the urban, ruralurban and rural-rural counties classifications. The county ruralness trends are presented in Tables 3.1 and 3.2. Figures 3.3 and 3.4 show the 2002 to 2006 trends in number of physicians and physician-population ratios for the four rural-urban commuting areas (RUCA) catagories. The urban areas had the greatest percentage increase (16%), followed by the large rural town areas (14%), and then followed by small rural town areas (Table 3.3). There was no change in the isolated small rural town areas. The noticeable inequalities in distribution in the physician-population ratios by ruralness are illustrated by the 2006 ratios for urban areas (240 per 100,000), large rural town areas (150 per 100,000), small rural town areas (107 per 100,000), and isolated small rural town areas (58 per 100,000). Table 3.4 shows the five year trends. Total Allopathic Physicians: There were 11,936 active licensed allopathic physicians in the state in During the five year period ( ), there was a 14% increase (+1,485) in number of licensed MDs (Table 3.5). Similar increase in number of MDs occurred in all three county-ruralness categories; however, four of the rural-rural classified counties showed a decrease: Apache (-26%), Gila (-9%), La Paz (-8%) and Graham (-4%). The state MD-population ratio increased slightly from 192 per 100,000 in 2002 to 194 per 100,000 in 2006 (Table 3.6). The 2002 to 2006 MD-population ratios decreased in the rural-rural classified counties (from 101 to 100 per 100,000), while they increased for both the urban classified counties (from 216 to 218 per 100,000) and rural-urban classified counties (from 154 to 162 per 100,000). The 2006 county rankings of MD-population ratios are presented in Map 3.2. The three counties with the largest MD-population ratios in 2006 were: Pima (269 per 100,000), Coconino (216 per 100,000), and Maricopa (205 per 100,000), while the smallest were Apache (42 per 100,000), La Paz (60 per 100,000), and Pinal (65 per 100,000). Figures Map 3.2. Allopathic Physician-Population Ratios by AZ Counties for 2006 Source: ADHS 3.5 and 3.6 show the inequalities of MD numbers and MD-population ratios among the urban and rural counties during The 2002 to 2006 trends of MD numbers and MD-population ratios for four RUCA categories are shown in Figures 3.7 and 3.8. The urban areas had the greatest increase in numbers of allopathic physicians (15%), followed by large rural town areas (10%), followed by small rural town areas (6%), and then by small isolated rural town areas (2%) (Table 3.7). The wide distribution inequalities existed from 2002 to 2007 in the physician-population ratios between the urban RUCA category and three rural categories. The trends are presented in Table 3.8. Total Osteopathic Physicians: There were 1,493 active licensed osteopathic physicians (DO) in Arizona in During the five year period (2002 to Figure 3.3. Total Physicians (MD and DO) Profile for Arizona s Four Rural Urban Communting Areas: Figure 3.4. Total Physicians (MD and DO) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Claritas.

19 2006), the number of DOs increased 30 percent (+341) (Table 3.9). The percent increase was the same for all three county ruralness categories. The number of DOs decreases for three of the rural-rural classified counties: Greenlee (-100%), Apache (-17%), and Cochise (-4%) counties. The 2002 to 2006 state wide DO-population ratios increased from 21 to 24 per 100,000 (Table 3.10). All of the county-ruralness categories increased from 23 to 26 per 100,000 for urban counties, from 12 to 14 per 100,000 for rural-urban counties, and from 17 to 19 per 100,000 for rural-rural counties. The 2006 county ranking in DO-population ratios are shown in Map 3.3. The three counties with the largest DO-population ratios in 2006 were Mohave (32 per 100,000), La Paz (30 per 100,000), and Gila (29 per 100,000), while the smallest were Greenlee (0), Santa Cruz (5 per 100,000) and Apache (7 per 100,000). Figures 3.9 and 3.10 show the distribution inequality of DO numbers and DO-population ratios among the three county ruralness categories. Figures 3.11 and 3.12 show the 2002 to 2006 trends for DO numbers and DO-population ratios in the four categories of RUCAs. The large rural town category had the greatest percentage increase in number of licensed DOs (42%), followed by urban areas (29%) and then followed by small rural town areas (24%). The small isolated rural town areas had a decrease of the number of DOs Map 3.3. Osteopathic Physician-Population Ratios by AZ Counties for 2006 Source: ADHS (-13%). In 2006, the DO-population ratios were 25 per 100,000 for both urban and large rural town areas, 19 per 100,000 small rural town areas and 7 per 100,000 isolated rural town areas (Tables 3.11 and 3.12). Figure 3.5. Total Allopathic Physician (MD) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.6. Total Allopathic Physicians (MD) per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: Source: Arizona Board of Medical Examiners Allopathic Physician Files Figure 3.7. Total Allopathic Physician (MD) Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Medical Examiners Allopathic Physician Files Population estimates provided by the U.S. Census Bureau. Figure 3.8. Total Allopathic Physicians (MD) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Medical Examiners Allopathic Physician Files Source: Arizona Board of Medical Examiners Allopathic Physician Files Population estimates provided by Claritas. 3-3

20 Primary Care Physicians: Unless otherwise stated in this report, primary care physicians include both allopathic physicians (MDs) and osteopathic physicians (DOs) with active licenses, residing in Arizona, whose primary or secondary specialty is one of the primary health care specialties: family practice, general practice, internal medicine, or pediatrics. Even though general surgeons and obstetrics/gynecology may provide primary care services, especially in the rural areas, they were classified specialist physicians and not as primary care physicians. In 2006, there were 4,424 active licensed primary care physicians in Arizona. There was an 18 percent increase of primary care physicians (+680) from 2002 to 2006 (Figures 3.13 and Table 3.14). Over the five-year period, the increase in number of primary care physicians was greater in the rural-urban classified counties (20%) than in the urban classified counties (18%) and rural-rural classified counties (16%). However, greater increases in the number of primary care physicians occurred in the urban counties (+567) than in the rural-urban (+33) and rural-rural counties (+80). The number of primary care physicians in three counties did not change or decreased: Greenlee (0%), Apache (-23%), and Santa Cruz (-10%) counties. Pinal (33%), Yuma (32%), and Mohave Counties (28%) showed the greatest increase in primary care physicians. There was a greater increase in the number of primary care MDs (+498, 16%) than DOs (+182, 28%) from 2002 to The two urban counties had the greatest increase in numbers of primary care MDs (+409, 82.1%) and DOs (+158, 86.8%). Figures 3.15 and 3.16 and Tables 3.15 and 3.16 describe the state and county changes in the numbers of MDs and DOs Figure 3.9. Total Osteopathic Physician (DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure Total Osteopathic Physicians (DO) per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Figure Total Osteopathic Physician (DO) Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. Figure Total Osteopathic Physicians (DO) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Claritas.

21 during The New York Center for Health Workforce Studies reported that in 2004 Arizona was ranked 39th nationally in primary care physician-population ratios. 2 Arizona had 67.6 primary care physicians per 100,000 population, while the U.S. had 76.6 per 100, This national study used data from the Health Resource File that was provided by the American Medical Association and the American Osteopathic Association. The physician counts comprised those MDs and DOs who provided non-federal patient care. Residents and fellows were excluded. The primary care physician-population ratio in this study increased from 69 per 100,000 in 2002 to 72 per 100,000 in 2006 (Figure 3.14). The two urban classified counties increased Map 3.4. Primary Care from 74 to 77 per 100,000 and Physician-Population the rural-urban classified Ratios by AZ Counties counties increased from 57 for 2006 to 63 per 100,000. There was no change in the rural-rural classified counties (51 per 100,000) from 2002 to The inequalities of primary care physician-population ratios between the urban and rural counties remained the same between 2002 and Ranking of primary care physicianpopulation ratios in 2006 Source: ADHS are presented in Map 3.4. The three counties with the largest primary physician- Figure Total Primary Care Physician (MD and DO) Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: Figure Total Primary Care Physicians (MD and DO) per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Figure Allopathic Primary Care Physicians (MD) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. Figure Osteopathic Primary Care Physician (DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Source: Arizona Board of Medical Examiners Allopathic Physician Files Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files,

22 population ratios were: Pima (84 per 100,000), Coconino (77 per 100,000), and Maricopa (76 per 100,000), while the smallest were Apache (29 per 100,000), Pinal (41 per 100,000), and Santa Cruz (43 per 100,000) counties. The 2002 to 2006 trends in number of primary care physicians and primary care physician-population ratios for the four categories of RUCAs are shown in Figures 3.17 and The urban and large rural town areas had the largest increase of primary care physicians (19%), and the small and isolated rural town areas had the smallest increase of primary care physicians (4%) (Table 3. 17). The inequalities in distribution of primary care physician-population ratios by ruralness continued from 2002 to 2006 (Table 3.18). The Health Resources and Services Administration (HRSA) has defined a primary care health professional shortage area (HPSA) as an area that has a population to full-time equivalent (FTE) primary care physician ratio of at least 3,500:1 (28.6 physicians per 100,000 population). 3 However, an area with unusually high needs for primary care services or insufficient capacity of existing primary care providers can have a ratio of 3,000:1 (33.3/100,000). The limits set by HRSA are based on FTE estimates of direct patient care physicians and not on licensing board data that is presented in this report. The number of physicians in this report is based on actively licensed individuals not FTEs, and also includes part-time physicians and non-direct care physicians such as administrators, researchers, and educators. The primary care physician-population ratios in this report (Figure 3.18) exceed the HPSA limits because the licensure data that was used overestimated physician FTEs and HPSAs are smaller, geographically targeted areas than the counties and ruralness classifications used in this report. Map 3.5 summarizes the 2010 primary care HPSAs in the state. Specialist Physicians: Those MD and DO physicians who are not classified as primary care practitioners are classified as specialists. There were twice as many active licensed specialist physicians (9,005) than primary care physicians (4,424) in Map 3.5. Arizona Primary Care Health Professional Shortage Areas: February Source: ADHS Figure Total Primary Care Physician (MD and DO) Profile for Arizona s Four Rural Urban Commuting Areas: Figure Total Primary Care Phyysicians (MD and DO) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Claritas. 3-6

23 Arizona in During the five-year period from 2002 to 2006, there was a greater increase in the number of specialist physicians (+1,146, 15%) than primary care physicians (+680, 18%). The rural-rural classified counties had the largest percent increase (16%, +107) in number of specialist physicians compared to the other two county-ruralness categories. Figure 3.19 and Table 3.19 show the specialist physicians five-year trends. The number of active licensed specialist physicians increased in the three county-ruralness categories: 15 percent (+1,001) in the urban counties, 12 percent (+38) and in the rural-urban counties, and 16 percent (+107) in the rural-rural counties. The number of specialist physicians decreased in three rural-rural classified counties: 26 percent (-5) in Apache, 2 percent (-2) in Cochise, and 2 percent (-1) in Gila. There were no changes in La Paz County. The greatest percentage increase in specialist physicians occurred in Greenlee (33%, +1), Pinal (29%, +20), and Mohave (28%, +46). The remaining counties also showed increases. From 2002 to 2006 there was a slight increase in statewide specialist physician-population ratios from 144 to 146 per 100,000 (Figure 3.20 and Table 3.20). Increases occurred in both the urban (from 165 to 167 per 100,000) and rural-urban (from 109 to 113 per 100,000) county classifications. There was no net change in the rural-rural counties during the five years (68 per 100,000). Map 3.6 shows the county rankings of specialist physician-population ratios in The three counties with the largest specialist physician-population ratios in 2006 were Pima (205 per 100,000), Coconino (158 per 100,000), and Maricopa (157 per 100,000) counties, while the smallest were Apache (20 per 100,000), Graham (27 per 100,000 ) and Pinal (33 per 100,000) counties. Map 3.6. Specialist Physician-Population Ratios by AZ Counties for 2006 The number of specialist MDs increased 13 percent (+987) while the number of specialist DOs increased by 31 percent (+159) from 2002 to 2006 (Figures 3.21 and 3.22). Specialist MDs comprise Source: ADHS 86.1 percent of all specialist physicians. The trends for specialist MDs and DOs are presented in Tables 3.21 and 3.22, respectively. Figures 3.23 and 3.24 show the five-year trends of the four Rural Urban Commuting Area categories. The urban areas had the greatest increase in number of specialist physician (1,087, 15%), followed by large rural town areas (37, 11%) and then followed by small rural town areas (24, 13%). Analysis by RUCA categories from 2002 to 2006 identified a 13 percent (-2) decrease in specialist physicians for small isolated rural town areas and a decreased from 16 to 13 specialist physicians per 100,000. The urban areas had the greatest increase in physicians per 100,000 population from 2002 to 2006 (159 to 164 per 100,000). The five year trends are shown in Tables 3.23 and Figure Total Specialist Physician (MD and DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure Total Specialist Physicians (MD and DO) per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. 3-7

24 Figure Allopathic Specialist Physician (MD) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure Osteopathic Specialist Physician (DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Source: Arizona Board of Medical Examiners Allopathic Physician Files Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Figure Total Specialist Physician (MD and DO) Profile for Arizona s Four Rural Urban Commuting Areas: Figure Osteopathic Specialist Physician (MD) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Claritas. Obstetrics and Gynecology Physicians: Figure 3.25 and Table 3.25 summarize the state and county 2002 to 2006 trends for obstetrics and gynecology physicians (OB/GYN). There was an increase of 7 percent (51) from 2002 to 2006, while the ratio of OB/ GYNs decreased from 62 to 60 per 100,000 women of child bearing age (15 to 44 years old) (Figure 3.26 and Table 3.26). This decrease occurred in all three county ruralness categories: from 65 to 64 per 100,000 for urban counties, from 58 to 52 per 100,000 for ruralurban counties, and from 45 to 43 per 100,000 for ruralrural counties. The 2006 county rankings for number of OB/GYNs per 100,000 women of child baring age are presented in Map 3.7. The three counties with the largest OB/GYN-population ratios were Coconino (74 per 100,000), Pima (68 per 100,000) and Maricopa (64 per 100,000), while the smallest were Greenlee (0), Pinal (22 per 100,000), and Yuma (34 per 100,000). The urban classified counties Map 3.7. OB/GYN had a greater increase in the Physician-Women number of OB/GYNs (7%, of Child-Bearing Age +43) than the rural-urban Ratios by AZ Counties classified counties (13%, 10). for 2006 The number of OB/GYNs in rural-rural classified counties decreased 6 percent (-2). There were no OB/GYNs in Greenlee County from 2002 to The number of OB/ GYNs decreased 9 percent (-2) in Coconino, 29 percent (-2) in Gila, and 10% (-1) in Navajo counties from 2002 to Source: ADHS There were no changes in the number of OB/GYNs in Apache (5), Cochise (10), Santa Cruz (4), and 3-8

25 Figure Total Obstetrics/Gynecology Physician (MD and DO) Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: Figure Total Obstetrics/Gynecology Physicians (MD and DO) per 100,000 Women of Child-Bearing Age (15-44 Years Old) Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. Figure Allopathic (MD) Obstetrics/Gynecology Physician Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: Figure Osteopathic (DO) Obstetrics/Gynecology Physician Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Allopathic Physician Files Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Yuma (12) counties during the five-year time period. The greatest increase in the number of OB/GYNs in a rural-rural classified county occurred in Yavapai County (46%, from 13 to 19). From 2002 to 2006 the number of allopathic OB/ GYNs increased 6 percent (+38) while the number of osteopathic OB/GYNs increased 24 percent (+13) (Figures 3.27 and 3.28). Allopathic OB/GYNs comprises 91 percent of all OB/GYNs in Arizona. The five year trends for allopathic and osteopathic OB/ GYNs are presented in Tables 3.27 and The 2002 to 2006 trends of OB/GYNs in the four RUCA categories are shown in Figures 3.29 and The urban areas had the greatest increase in number of OB/GYNs (8%), followed by large rural town areas (5%), then by small rural town areas (3%) (Table 3.29). The inequalities in OB/GYN coverage between urban and rural areas continued from 2002 to 2006 with larger numbers of OB/GYNs per 100,000 population located in the more urbanize areas. The five year trends are presented in Table Psychiatric Physicians: There were 712 active licensed psychiatric physicians in Arizona in From 2002 to 2006 the number of psychiatric physicians increased by 8 percent (+54) (Table 3.31). Both the urban classified (+52) and rural-rural classified (+5) counties increased 9 percent during the five year period, while the two rural-urban counties (-3) decreased by 10 percent. The number of psychiatric physicians decreased 60 percent in Navajo County, 33 percent in Yuma County, and 13 percent in Cochise County. Greenlee, La Paz, and Santa Cruz counties had no psychiatric physicians. 3-9

26 Figure Total Obstetrics/Gynecology Physician (MD and DO) Profile for Arizona s Four Rural Urban Commuting Areas: Figure Total Obstetrics/Gynecology Physicians (MD and DO) per 100,000 Women of Child Bearing Age (15-44 Years Old) Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Figure Psychiatric Physician (MD and DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Claritas. Figure Psychiatric Physicians (MD and DO) per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Psychiatric Physician Files 2008 and Arizona Department of Health Services,Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, Sources: Arizona Board of Medical Examiners Psychiatric Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. The number of psychiatric physicians decrease state wide from 12.1 to 11.6 per 100,000 population from 2002 to 2006 (Table 3.32) and in all the county-ruralness categories: from 14 to 13 per 100,000 in urban counties, 10 to 8 per 100,000 in rural-urban counties, and 6 to 5 per 100,000 in rural-rural counties. Map 3.8 shows the 2006 county rankings of psychiatric physician-population ratios. The three counties with the largest psychiatric physician-population ratios in 2006 were Pima (19 per 100,000), Coconino (16 per 100,000), and Greenlee (13 per 100,000) counties. The smallest were Graham (0), La Paz (0), and Santa Cruz (0) counties. Greenlee County s one psychiatric physician resulted in relatively high ratio of 13 psychiatric physicians per 100,000 population because of the county s relatively small population of 7,469. Figures 3.31 and 3.32 show the distribution inequalities of psychiatric physician numbers and population ratios among the urban and rural counties. Map 3.8. Psychiatric Physician-Population Ratios by AZ Counties for 2006 Figures 3.33 and 3.34 show the five-year trends of psychiatric physicians in the four RUCA categories. The large rural town areas had the greatest Source: ADHS increase in number of psychiatric physicians (22%), followed by the urban 3-10

27 Figure Psychiatric Physician (MD and DO) Profile for Arizona s Four Rural Urban Commuting Areas: Figure Psychiatric Physicians (MD and DO) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona Board of Medical Examiners Psychiatric Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, Sources: Arizona Board of Medical Examiners Psychiatric Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, Population estimates provided by Nielsen-Claritas. areas (8%). The number of psychiatric physicians were the same in 2002 and 2006 for small rural town areas and small isolated rural town areas. In 2006, urban areas continued to have more psychiatric physicians per 100,000 population than the rural town areas. The five-year trends are shown in Tables 3.33 and Satisfying Future Physician Demand Healthcare workforce issues and policies have taken greater urgency for Arizona since the 2010 passage of the Patient Protection and Affordable Care Act. This act is expected to increase the demand for physicians because of increased number of people accessing regular healthcare. As a result, the nationwide demand for physicians will increase faster than the current education and residency programs can produce new physicians. State-to-state competition for physicians is expected to increase. Arizona depends on other states and countries to produce the majority of primary care physicians that serves its population. Among the 4,220 direct, primary care physicians practicing in Arizona in 2008, 60.9 percent did not attend medical school or residency training in Arizona and were recruited from other states or countries, 26.5 percent only received their residency training in Arizona, and the remainder (12.6%) graduated from a medical school in Arizona. Medical residency programs in Arizona have resulted in a disproportionate number of primary care physicians establishing their practice in urban areas (Tables 3.35 and 3.36). 3.3 Physician Practice Profile The Center for Health Information and Research (CHIR) estimated that in 2004 approximately 87 percent of Arizona licensed physicians (MDs and DOs) had a practice involving direct patient care, four percent were teaching or conducting research, 1 percent were administrators, 2 percent were in training, and 6 percent were retired, semi-retired, or on leave. 4 Based on 2008 AMA data of actively working physicians (MDs and DOs) in Arizona, 95.1 percent provided direct patient care, 2.0 percent were administrators, 1.3 percent were teachers, 1.0 percent were researchers and 0.6 percent had other non-direct care employment. The CHIR also estimated that physicians saw an average of 84 patients per week during that same period of time. 5 However, the number of patient visits per week varied by specialty from 37 per week for anesthesiologists to 106 for cardiologists. Family practitioners averaged 95 visits per week. Physicians practicing in rural areas averaged more visits per week than in urban areas Summary In 2006, Arizona had 13,429 active licensed physicians. Of these, 88.9 percent were allopathic physicians. Eighty-six percent of Arizona s 13,429 active licensed physicians were located in Maricopa and Pima counties in In contrast, the rural counties of Greenlee, La Paz and Graham experienced the smallest number of licensed physicians in the state. Arizona had 218 physicians per 100,000 population in The largest number of physicians per 100,000 population occurred in counties large population centers, Pima, Coconino, and Maricopa counties. The 3-11

28 smallest physician-population ratios occurred in three rural-rural classified counties: Apache, Pinal, and Santa Cruz. While the number of physicians in Arizona increased by 16 percent (+1,826) from 2002 to 2006, there was a small increase in the physician-population ratio, from 213 to 218 per 100,000 over the same time period. The number of allopathic physicians (MDs) increased 14 percent and the number of osteopathic physicians (DOs) increased 30%. The number of physicians increased by 16 percent in both the urban classified counties (Maricopa and Pima) and in the rural-rural classified counties. The number of physicians in rural-urban classified counties increased 15 percent. Inequalities in the distribution of physician continued to occur between urban and rural counties. There were twice as many specialist physicians than primary care physicians in The physicianpopulation ratios show wider urban-rural inequalities for specialist physicians than primary care physicians with rural areas having smaller physician-population ratios. From 2002 to 2006, the number of specialist physicians (+1,146, 15%) increased more than primary care physicians (+680, 18%). Although the number of obstetrics and gynecology physicians (OB/GYN) increased 7 percent during the five-year period, the increase did not keep up with the state s population increase. The number of OB/GYNs per 100,000 women of child bearing age decreased from 62 to 60. This decrease occurred in all three county-ruralness categories: from 65 to 64 per 100,000 for urban counties, from 58 to 52 per 100,000 for rural-urban counties, and from 45 to 43 per 100,000 for rural-rural counties. Although the number of psychiatric physicians increased by 8 percent from 2002 to 2006, there was a noticeably decreased from 2005 to 2006 for all ruralness categories. The number of psychiatric physicians per 100,000 population in the state slightly peaked in 2005 (13 per 100,000) then returned to the 2002 value in 2006 (12 per 100,000). In the rural-rural classified counties from 2002 to 2006 Graham, La Paz, and Santa Cruz counties had no psychiatric physicians the number of psychiatric physicians decreased 60 percent (-3) in Navajo County, 33 percent (-3) in Yuma County, and 13 percent (-1) in Cochise County. Rural and urban inequalities in the distribution of primary care and specialist physicians was evident between 2002 and 2006, even through their numbers increased in the state as a whole. 3.5 References 1. Gordon, R. J. (1987). Arizona Rural Health Provider Atlas, Rural Health Office, Department of Family and Community Medicine, University of Arizona College of Medicine. pp The New York Center for Health Workforce Studies (2006). The United States Workforce Profile, Health Resources and Services Administration, DHHS. pp Health Resources and Services Administration, Bureau of Health Professionals, Primary Medical Care HSPA Designation Overview. (2009) Retrieved on October 29, 2010 on the World Wide Web: 4. Johnson, W.G., Rimsza, M.E., Garcy T., and Grossman M. (2005). The Arizona Physician Workforce Study Part 1: The Number of Practicing Physicians Center for Health Information and Research, Arizona State University, Tempe. pp Rimsza, M.E., Johnson, W.G., Speicher M., and Grossman M. (2005). The Arizona Physician Workforce Study Part 2: The Number of Practicing Physicians Center for Health Information and Research, Arizona State University, Tempe. pp

29 Table 3.1. Total Physicians (MDs and DOs): Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from Percent Change 2002 to 2006 from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 7,427 8,794 1,367 18% Mohave % Navajo % Pima 2,540 2, % Pinal % Santa Cruz % Yavapai % Yuma % Arizona - Total 11,603 13,429 1,826 16% Urban Counties 9,967 11,535 1,568 16% Rural-Urban Counties % Rural-Rural Counties 1,160 1, % Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table 3.2. Total Physicians (MDs and DOs) per 100,000 Population: Arizona County Changes between County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. 3-13

30 Table 3.3. Total Physicians (MDs and DOs): Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Arizona - Total 11,603 13,429 1,826 16% Urban 10,612 12,328 1,716 16% Large Rural Town % Small Rural Town % Isolated Small Rural Town % Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table 3.4. Total Physicians (MDs and DOs) per 100,000 Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Nielsen-Claritas. Table 3.5. Total Allopathic Physicians (MDs): Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 6,645 7,748 1,103 17% Mohave % Navajo % Pima 2,370 2, % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 10,451 11,936 1,485 14% Urban Counties 9,015 10,302 1,287 14% Rural-Urban Counties % Rural-Rural Counties 993 1, % Source: Arizona Board of Medical Examiners Allopathic Physician Files

31 Table 3.6. Total Allopathic Physicians (MDs) per 100,000 Population: Arizona County Changes between County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Source: Arizona Board of Medical Examiners Allopathic Physician Files Population estimates provided by the U.S. Census Bureau. Table 3.7. Total Allopathic Physicians (MDs): Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Arizona Total 10,451 11,936 1,485 14% Urban 9,603 11,023 1,420 15% Large Rural Town % Small Rural Town % Isolated Small Rural Town % Source: Arizona Board of Medical Examiners Allopathic Physician Files Table 3.8. Total Allopathic Physicians (MDs) per 100,000 Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Source: Arizona Board of Medical Examiners Allopathic Physician Files Population estimates provided by Nielsen-Claritas. 3-15

32 Table 3.9. Total Osteopathic (DO) Physicians: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 782 1, % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona - Total 1,152 1, % Urban Counties 952 1, % Rural-Urban Counties % Rural-Rural Counties % Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table Total Osteopathic Physicians (DOs) per 100,000 Population: Arizona County Changes between 2002 and 2006 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. 3-16

33 Table Total Osteopathic Physicians (DOs): Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Arizona Total 1,152 1, % Urban 1,009 1, % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table Total Osteopathic Physicians (DOs) per 100,000 Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Nielsen-Claritas. Table Primary Care Physicians (MDs and DOs): Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 2,369 2, % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 3,744 4, % Urban Counties 3,085 3, % Rural-Urban Counties % Rural-Rural Counties % Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files,

34 Table Primary Care Physicians (MDs and DOs) per 100,000 Population: Arizona County Changes between 2002 and 2006 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona - Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. Table Allopathic (MD) Primary Care Physicians: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 1,934 2, % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 3,100 3, % Urban Counties 2,559 2, % Rural-Urban Counties % Rural-Rural Counties % Source: Allopathic Physician Statistical Files,

35 Table Osteopathic (DO) Primary Care Physicians: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total % Urban Counties % Rural-Urban Counties % Rural-Rural Counties % Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table Primary Care Physicians (MDs and DOs): Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 RUCA Number in 2002 Number in 2006 Arizona Total 3,744 4, % Urban 3,300 3, % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table Primary Care Physicians (MDs and DOs) per 100,000 Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Nielsen-Claritas. 3-19

36 Table Total Physician Specialists (MDs and DOs): Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 5,058 5, % Mohave % Navajo % Pima 1,824 1, % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 7,859 9,005 1,146 15% Urban Counties 6,882 7,883 1,001 15% Rural-Urban Counties % Rural-Rural Counties % Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table Total Physician Specialists (MDs and DOs) per 100,000 Population: Arizona County Changes between 2002 and 2006 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona - Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. 3-20

37 Table Allopathic (MD) Specialist Physicians: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 4,711 5, % Mohave % Navajo % Pima 1,745 1, % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 7,351 8, % Urban Counties 6,456 7, % Rural-Urban Counties % Rural-Rural Counties % Source: Arizona Board of Medical Examiners Allopathic Physician Files Table Osteopathic (DO) Specialist Physicians: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham NA Greenlee NA La Paz % Maricopa % Mohave % Navajo % Pima % Pinal % Santa Cruz NA Yavapai % Yuma % Arizona Total % Urban Counties % Rural-Urban Counties % Rural-Rural Counties % Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files,

38 Table Specialist Physicians (MDs and DOs): Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 RUCA Number in 2002 Number in 2006 Arizona Total 7,859 9,005 1,146 15% Urban 7,312 8,399 1,087 15% Large Rural Town % Small Rural Town % Isolated Small Rural Town % Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table Specialist Physicians (MDs and DOs) per 100,000 Population: Arizona s Four Rural- Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Nielsen-Claritas. Table Obstetrics/Gynecology Physicians (MDs and DOs): Arizona County Changes Between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee NA La Paz NA Maricopa % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total % Urban Counties % Rural-Urban Counties % Rural-Rural Counties % Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files,

39 Table Obstetrics/Gynecology Physicians (MDs and DOs) per 100,000 Women of Child- Bearing Age (15 44 y/o): Arizona County Changes Between 2002 and 2006 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. Table Allopathic (MD) Obstetrics/Gynecology Physicians: Arizona County Changes between 2002 and 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 County Number in 2002 Number in 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee NA La Paz NA Maricopa % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total % Urban Counties % Rural-Urban Counties % Rural-Rural Counties % Source: Allopathic Physician Statistical Files,

40 Table Osteopathic (DO) Obstetrics/Gynecology Physicians: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino NA Gila NA Graham NA Greenlee NA La Paz NA Maricopa % Mohave % Navajo % Pima % Pinal % Santa Cruz NA Yavapai NA Yuma NA Arizona Total % Urban Counties % Rural-Urban Counties NA Rural-Rural Counties % Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table Obstetrics/Gynecology Physicians (MDs and DOs): Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 RUCA Number in 2002 Number in 2006 Arizona Total % Urban % Large Rural Town % Small Rural Town % Isolated Small Rural Town NA Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Table Obstetrics/Gynecology Physicians (MDs and DOs) per 100,000 Women of Child Bearing Age: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, Population estimates provided by Nielsen-Claritas. 3-24

41 Table Psychiatric Physicians (MD and DO): Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham NA Greenlee NA La Paz NA Maricopa % Mohave % Navajo % Pima % Pinal % Santa Cruz NA Yavapai % Yuma % Arizona - Total % Urban Counties % Rural-Urban Counties % Rural-Rural Counties % Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, Table Psychiatric Physicians (MD and DO): per 100,000 Population: Arizona County Changes between 2002 and 2006 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, Population estimates provided by the U.S. Census Bureau. 3-25

42 Table Psychiatric Physicians (MD and DO): Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Arizona Total % Urban % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, Table Psychiatric Physicians (MD and DO) per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, Population estimates provided by Nielsen-Claritas. Table Direct, Primary Care Physician Coverage per 100,000 Population in 2008 by Arizona County Classification of Ruralness All Physicians No Arizona Residency Contribution Contribution Arizona Residency Urban Rural-Urban Rural-Rural Source: American Medical Association (AMA) physician data file and US Census population estimates. Note: 2008 AMA dataset included medical residency and other information not available in Arizona Medical Board data used in this report. Table Direct, Primary Care Physician Coverage per 100,000 Population in 2008 by Zip Code based Arizona Rural-Urban Commuting Areas Classification All Physicians No Arizona Residency Contribution Contribution Arizona Residency Urban Large rural town Small rural town Isolated small rural town Source: American Medical Association (AMA) physician data file and Nielsen-Claritas population estimates. Note: 2008 AMA dataset included medical residency and other information not available in Arizona Medical Board data used in this report. 3-26

43 SECTION 4: PHYSICIAN ASSISTANTS In 2007, there were 1,455 active licensed physician assistants (PAs) in Arizona. Physician assistants are considered mid-level health care practitioners and provide primary care services under the responsible supervision of a licensed physician. 1 Physician assistants and nurse practitioners (Section 5) serve similar middle level roles. The Arizona Medical Board of Examiners collects data on PA data as part of licensing and license renewal. Arizona Department of Health Services (ADHS) was the source of the PA data from 2002 to 2006 and the Arizona Medical Board of Examiners was the source of the 2007 PA data. There was a 59 percent increase (+541) in physician assistants from 2002 to 2007 (Figure 4.1 and Table 4.1). The increase in number of physician assistants from 2002 to 2007 was 70 percent (+474) in the urban classified counties, 33 percent (+20) in the rural-urban classified counties, and 27 percent (+47) in the ruralrural classified counties. The three counties with the greatest increases in PAs from 2002 to 2007 were Maricopa (70%,+418), Pinal (70%, +19), and Pima (66%, +56) counties. The number of PAs decreased in 6 of rural-rural classified counties: 50 percent decrease (-1) in Santa Cruz County, 43 percent decrease (-3) in Greenlee County; 38 percent decrease (-6) in Apache County, 33 percent decrease (-1) in La Paz County, 17 percent decrease (-2) in Gila County, and 5 percent decrease (-1) in Cochise County. The New York Center for Health Workforce Studies reported that Arizona was ranked 10th nationally in availability of PAs for 2004 with 9.2 PAs per 100,000 population; the US average was 7.8 per 100, This national study used data from the American Academy of Physician Assistants and reported a much smaller coverage of PAs numbers than was determined from the Arizona Medical Board of Examiners data for 2004 (20 PAs per 100,000). State wide, PAs increased from 17 to 23 per 100,000 population from 2002 to 2007 (Figure 4.2 and Table 4.2). The increase in PA-population ratios occurred in all three county ruralness categories: from 16 to 24 per 100,000 in urban classified counties; from 21 to 25 per 100,000 in rural-urban classified counties; and from 18 to 19 in rural-rural classified counties. The 2007 county rankings of PAs-population ratios are presented in Map 4.1. The three counties with the largest Map 4.1. Physician PA-population ratios in 2007 Assistants-Population were Greenlee with 52 PAs per Ratios by AZ Counties 100,000, Graham with 35 per for ,000, and Coconino with 32 per 100,000. The smallest ratios were Santa Cruz with 2 per 100,000, La Paz with 10 per 100,000, and Apache with 14 per 100,000. Figures 4.3 and 4.4 show the 2002 to 2007 trends in number of PAs and PA- Source: ADHS Figure 4.1. Physician Assistant Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: Figure 4.2. Physician Assistants per 100,000 Population Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: Sources: Arizona Board of Medical Examiners Physician Assistant Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Physician Assistant Statistical Files, Sources: Arizona Board of Medical Examiners Physician Assistant Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Physician Assistant Statistical Files, Population estimates provided by the U.S. Census Bureau. 4-1

44 Figure 4.3. Physician Assistant Profile for Arizona s Four Rural Urban Commuting Areas: Figure 4.4. Physician Assistants per 100,000 Population Profilefor Arizona s Four Rural Urban Commuting Areas: Sources: Arizona Board of Medical Examiners Physician Assistant Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Physician Assistant Statistical Files, Sources: Arizona Board of Medical Examiners Physician Assistant Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Physician Assistant Statistical Files, Population estimates provided by Claritas. population ratios for the four rural urban commuting area (RUCA) categories. The urban areas had the greatest increase in PA numbers (70%), followed by the large rural town areas (30%). The isolated small rural town areas had the smallest increase in number of PAs (20%) and the small rural town areas had a small decrease (-4%) (Table 4.3). The number of PAs per 100,000 population increased from 16 in 2002 to 24 in 2007 for urban areas, from 21 to 24 for the large rural town areas, and from 10 to 11 for the isolated small rural town areas. Small rural town areas decreased from 23 to 20 per 100,000. The distribution of inequalities in PAs by ruralness was most apparent for the isolated small rural town areas. Table 4.4 presents the six year trend. 4.1 Summary The number of physician assistants in the state increased by 59 percent (+541) from 2002 to The state wide number of PAs per 100,000 population increased from 17 in 2002 to 23 in The urban counties comprised 87.6 percent of the total increase in the number of PAs: Maricopa County increased by 418 PAs and Pima County increased 56 PAs over the 6 year period. In 2007, nurse practitioners (2,294) outnumbered PAs (1,455) state wide but their rate of increase (52% in 6 years, Section 5) was slightly less than the PAs rate of increase. Six of the rural-rural classified counties (Santa Cruz, Greenlee, Apache, La Paz, Gila, and Cochise counties) declined in number of physician assistants over the six year period. Inequalities in the distribution of physician assistants were most apparent for the isolated small rural town category using RUCA classification. 4.2 References 1. Gordon, R. J. (1987). Arizona Rural Health Provider Atlas, Rural Health Office, Department of Family and Community Medicine, University of Arizona College of Medicine. pp The New York Center for Health Workforce Studies (2006). The United States Workforce Profile, Health Resources and Services Administration, DHHS. pp

45 Table 4.1. Physician Assistants: Arizona County Changes between 2002 and 2007 County Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 593 1, % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona - Total 914 1, % Urban Counties 678 1, % Rural-Urban Counties % Rural-Rural Counties % Sources: Arizona Board of Medical Examiners Physician Assistant Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Physician Assistant Statistical Files, Table 4.2. Physician Assistants per 100,000 Population: Arizona County Changes between County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona Board of Medical Examiners Physician Assistant Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Physician Assistant Statistical Files, Population estimates provided by the U.S. Census Bureau. 4-3

46 Table 4.3. Physician Assistants: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Arizona - Total 914 1, % Urban 741 1, % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Sources: Arizona Board of Medical Examiners Physician Assistant Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Physician Assistant Statistical Files, Table 4.4. Physician Assistants per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona Board of Medical Examiners Physician Assistant Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Physician Assistant Statistical Files, Population estimates provided by Nielsen-Claritas. 4-4

47 SECTION 5: NURSES This section includes six categories of nurses: registered nurses (RN), certified registered nurse anesthetists (CRNA), nurse practitioners (NP), certified nurse midwives (CNM), licensed practical nurses (LPN), and certified nurse assistants (CNA). The Arizona State Board of Nursing collected the data as part of licensing and license renewal. Arizona Department of Health Services (ADHS) was the source of the nursing data from 2002 to 2006 and the Arizona State Board of Nursing was the source for the 2007 data. The highest level of certification or license that an individual had was used to avoid double counting individuals with multiple different certifications or licenses. Registered Nurses: Registered nurses (RN) are responsible for the type and quality of all nursing care that patients receive. In addition to being the primary link between patients and physicians, they supervise licensed practical nurses and other health professionals. 1 In 2007, there were 52,395 RNs in the state with active Arizona licenses. There was an 18% state wide increase (+7,889) registered nurses from 2002 to 2007 (Figure 5.1 and Table 5.1). The greatest percent increase in number of RNs occurred in the rural-rural classified counties (25%, +1,568) followed by the rural-urban classified counties (24%, +477) and urban classified counties (16%, +5,844). During this sixyear period, there was an increase in number of RNs in all 15 Arizona counties and ranged from 3 percent in Gila County to 63 percent in Pinal County. State wide the number of RNs per 100,000 population increased from 817 in 2002 to 827 in 2007 (Figure 5.2 and Table 5.2). An increase in RN-population ratios occurred in all three county ruralness classifications: from 866 to 867 per 100,000 in urban counties; from 681 to 764 per 100,000 in rural-urban counties; and from 651 to 678 per 100,000 in rural-rural counties. The state wide RN-population ratio peaked in 2004 at 853 per 100,000. The New York Center for Health Workforce Studies reported that Arizona was ranked 45th nationally for RN-population ratios in Arizona had 678 RNs per 100,000 population while the US average was 802 per 100, This national study used data from the Health Resources and Services Administration s 2004 National Sample Survey of Registered Nurses and reported smaller coverage of RNs than the 853 RNs per 100,000 determined from the 2004 Arizona State Board of Nursing data. Map 5.1 shows the 2007 county rankings of RN-population ratios. The three counties with the largest RNs per 100,000 population were Coconino (1,087), Pima (985), and Maricopa (837) counties. The three smallest RNs per 100,000 were La Paz (297), Santa Cruz (320), and Greenlee (361) counties. The RN-population ratios in the urban classified counties peaked in 2004 and then had a slight, steady decline. Maricopa County Map 5.1. Registered Nurses-Population Ratios by Arizona Counties for 2007 Source: Arizona Nursing Board Figure 5.1. Registered Nurse (RN) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 5.2. Registered Nurses (RNs) per 100,000 Population Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: Source: Arizona Board of Nursing, Registered Nurses File Source: Arizona Board of Nursing, Registered Nurses File Population estimates provided by the U.S. Census Bureau 5-1

48 declined from 866 per 100,000 in 2004 to 837 per 100,000 in Pima County declined from 1,022 per 100,000 in 2004 to 985 per 100,000 in Figures 5.3 and 5.4 show 2002 to 2007 trends in number of RNs and RN-population ratios for the four rural-urban commuting area (RUCA) categories. The urban areas had the largest increase in number RNs (18%) followed by large rural town areas (17%) (Table 5.3). The inequality in distribution of RNs per 100,000 population was apparent between each category of ruralness from 2002 to In 2007 there were 888 RNs per 100,000 in urban areas, 704 in the large rural town areas, 549 in the small rural town areas, and 401 in the isolated small rural town areas. Table 5.4 displays the six year trends. Certified Registered Nurse Anesthetists: In many parts of the country, there are large numbers of certified registered nurse anesthetists (CRNAs) who are trained to work in collaboration with anesthesiologists and physicians, or work independently. In 2007, there were 232 CRNAs with active Arizona licenses in the state, a 95 percent increase (+113) since Most (78.9%) of the 2007 CRNAs were located in the urban classified counties that also had the largest increase in numbers (103%, +93) from 2002 to 2007 (Figure 5.5 and Table 5.5). The state wide number of CRNAs per 100,000 population increased from 2 in 2002 to 4 in 2007 (Figure 5.6 and Table 5.6). Map 5.2 shows the 2007 county rankings of CRNAs per 100,000 population. The CRNA-population ratios increased in all three county ruralness categories: from 2 to 4 per 100,000 in urban counties, from 1 to 2 per 100,000 in ruralurban counties, and from 3 to 4 per 100,000 in ruralrural counties. The 2002 to 2007 trends of CRNA numbers and CRNA-population ratios for the four RUCA Figure 5.3. Registered Nurse (RN) Profile for Arizona s Four Rural Urban Commuting Areas: Figure 5.4. Registered Nurses (RNs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Nursing, Registered Nurses File Figure 5.5. Certified Registered Nurse Anesthetist (CRNA) Profile for Arizona and Urban/Rural-Urban/Rural- Rural Counties: Source: Arizona Board of Nursing, Registered Nurses File Population estimates provided by Claritas. Figure 5.6. Certified Registered Nurse Anesthetists (CRNAs) per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File Population estimates provided by the U.S. Census Bureau.

49 categories are shown in Figures 5.7 and 5.8. The largest increase in number of CRNAs during the six-year period occurred in the urban areas (+97) and large rural town areas (+14) (Table 5.7). There was an increase in number of CRNA-population ratios from 2 per 100,000 in 2002 to 4 per 100,000 in 2007 in the urban areas and from 4 to 6 per 100,000 in the large rural town areas (Table 5.8). Nurse Practitioners: Nurse practitioners (NP) are registered nurses who have Map 5.2. Certified Registered Nurse Anesthetists-Population Ratios by Arizona Counties for 2007 Source: Arizona Nursing Board completed additional training in specialty areas such as midwifery, pediatrics, family medicine, adult medicine, obstetrics-gynecology, and neonatal medicine. 1 They are certified by the Arizona State Board of Nursing in one or more specialty areas that allow them to assume many of the routine tasks of a physician (e.g., prescriptive authority). Nurse practitioners and physician assistants (Section 4) serve similar mid-level health practitioner roles. In Arizona, there were more NPs (2,294) than physician assistants (1,455) in The number of Arizona licensed NPs in the state increase 52% (+782) from 2002 to 2007 (Figure 5.9 and Table 5.9). The number of NPs per 100,000 population increased state wide from 28 in 2002 to 36 in 2007 (Figure 5.10 and Table 5.10). The NPs per 100,000 also increased in all three county ruralness categories: from 30 to 38 per 100,000 in urban counties, from 28 to 40 per 100,000 in rural-urban counties, and from 18 to 26 per 100,000 in rural-rural counties. The largest percent increase of NPs occurred in the Figure 5.7. Certified Registered Nurse Anesthetist (CRNA) Profile for Arizona s Four Rural Urban Commuting Areas: Figure 5.8. Certified Registered Nurse Anesthetists (CRNAs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File Figure 5.9. Nurse Practitioner (NP) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File Population estimates provided by Claritas. Figure Nurse Practitioners (NPs) per 100,000 Population Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: Source: Arizona Board of Nursing, Nurse Practitioners File 2008 Source: Arizona Board of Nursing, Nurse Practitioners File Population estimates provided by the U.S. Census Bureau. 5-3

50 rural-rural classified counties (73%, +127), followed by the rural-urban classified counties (57%, +46), and then the urban classified counties (48%, +609). Map 5.3 shows the 2007 county rankings of NPs per 100,000 population. The three counties with the largest NP-population ratios in 2007 were Coconino (72 per 100,000), Pima (50 per 100,000), and Maricopa (36 per 100,000) counties. The smallest NP-population ratios in 2007 were Greenlee (0), La Paz (15 per 100,000), and Graham (17 per 100,000) counties. Greenlee was the only county in the state that had no Arizona licensed NPs during the six-year period. The other 14 counties had increases Map 5.3. Nurse Practitioners- Population Ratios by Arizona Counties for 2007 Source: Arizona Nursing Board in NPs that range from +1 in La Paz County to +466 in Maricopa County during the same time period. The 2002 to 2007 trends of number of NPs and NPpopulation ratios for the four RUCA categories are shown in Figures 5.11 and The large rural town areas and small rural town areas had the largest percent increase of NPs (54%). The number of NPs increased 53% in the isolated rural town area and 52% in the urban areas (Table 5.11). The inequality in distribution of NPpopulation ratios was noticeable between the urban category and the 3 rural categories. The six-year trends are presented in Table Certified Nurse Midwives: Certified nurse midwives (CNM) are advanced practice, registered nurses (RNs) who have received additional education and training in midwifery the care of essentially healthy and normal mothers during pregnancy and childbirth. The nurse midwife provides care for the normally healthy mother during pregnancy and stays with her during labor, providing continuous physical and emotional support. 1 CNMs evaluate and provide immediate care for the normally healthy newborn, and help the mother to care for her infant and to adjust to the home situation for the new child. Nurse midwives are permitted to deliver babies in a hospital of low risk mothers while under the supervision of a physician, generally, an obstetrician. 1 In 2007 there were 156 Arizona licensed certified nurse midwives in the state. This was a 11 percent increase in CNMs (+16) from 2002 to 2007 (Figure 5.13 and Table 5.13). Statewide the number of CNWs per 100,000 women of child-bearing age in Arizona remained at 12 from 2002 to 2007 (Figure 5.14 and Table 5.14) The CNW-population ratios in the ruralrural classified counties decreased from 12 per 100,000 in 2002 to 10 per 100,000 in 2007, while the rural-urban classified counties increased from 23 to 25 per 100,000. There was no change in the urban classified counties (12 per 100,000). The 2007 county rankings of CNM-population ratio rankings are presented in Map 5.4. The four counties with the largest CNM-population ratios in 2007 were Apache (35 per 100,000), Navajo (31 per 100,000), Coconino (28 per 100,000) and Pima (28 per 100,000) counties. Greenlee, La Paz, Gila and Cochise counties did not have CNMs in Figures 5.15 and 5.16 show the 2002 to 2007 trends of the number of CNM and the CNM-population ratios for the four RUCA categories. Isolated small Figure Nurse Practitioner (NP) Profile for Arizona s Four Rural Urban Commuting Areas: Figure Nurse Practitioners (NPs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Nursing, Nurse Practitioners File Source: Arizona Board of Nursing, Nurse Practitioners File Population estimates provided by Claritas.

51 rural town areas had the largest percentage increase of CNM (100%, +1), followed by urban areas (13%, +16). There was no change for the large rural town areas and small rural town areas decreased (-7%, -1). The number of CNMs per 100,000 women of child-bearing age increased for the isolated small rural town areas from 5 in 2002 to 10 in 2007 and for the urban areas from 12 to 13. The large rural town areas maintained 4 CRNs per 100,000 in 2002 and Small rural town areas decreased from 21 to 18 per Map 5.4. Certified Nurse Midwives- Population Ratios by Arizona Counties for 2007 Source: Arizona Nursing Board 100,000. The six-year trends are shown in Tables 5.15 and Licensed Practical Nurses: Licensed practical nurses (LPN) provide nursing care to sick, injured and convalescent patients under the general supervision of physicians and registered nurses; they may also assist in the supervision of nursing aides, orderlies and attendants. 1 There were 9,241 LPNs in Arizona in During the six-year period from 2002 to 2007, there was a 32 percent increase state wide in the number of LPNs (+2,238) (Figure 5.17 and Table 5.17). The number of LPNs increased in all 15 Arizona counties.. The LPN-population ratios increased state wide from 129 per 100,000 in 2002 to 146 per 100,000 in 2007 (Figure 5.18 and Table 5.18) and in all three county ruralness categories (from 133 to 151 per 100,000 for the urban counties, from 69 to 86 per 100,000 for the rural-urban counties, and from 128 to 139 per 100,000 Figure Certified Nurse Midwife (CNM) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure Certified Nurse Midwives (CNMs) per 100,000 Women of Child Bearing Age (15-44 Year Old) Profile for Arizona and Urban/Rural- Urban/ Rural-Rural Counties: Source: Arizona Board of Nursing, Certified Midwives File Source: Arizona Board of Nursing, Certified Nurse Midwives File Population estimates provided by the U.S. Census Bureau Figure Certified Nurse Midwife (CNM) Profile for Arizona s Four Rural Urban Commuting Areas: Figure Certified Nurse Midwives (CNMs) per 100,000 Women of Child Bearing Age (15-44 Year Old) Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Nursing, Certified Nurse Midwives File Source: Arizona Board of Nursing, Certified Nurse Midwives File Population estimates provided by Claritas. 5-5

52 for the rural-rural counties). Map 5.5 shows the 2007 county rankings of LPN- population ratios. The three counties with the largest LPN-population ratios in 2007 were Gila (219 per 100,000), Pima (187 per 100,000), and Greenlee (168 per 100,000) counties. The three counties with the smallest ratios were Apache (66 per 100,000), Coconino (68 per 100,000), and La Paz (79 per 100,000) counties. Figures 5.19 and 5.20 show the 2002 to 2007 trends for Map 5.5. Licensed Practical Nurses- Population Ratios by Arizona Counties for 2007 Source: Arizona Nursing Board number of LPNs and number of LPNs per 100,000 population in the four RUCA categories. The number of LPNs in the urban areas increased 33% (+2,032), 26% (+70) in the small rural town areas and 21% (+119) in the large rural town areas. The LPN-population ratios increased from 132 per 100,000 in 2002 to 154 per 100,000 in 2007 for the urban areas and from 75 to 87 per 100,000 for the small rural town areas. The sixyear trends are shown in Tables 5.19 and Certified Nurse Assistants: Certified nurse assistants (CNA) are persons who assist individuals with healthcare needs and daily living activities under the supervision of RNs or LPNs. They provide bedside care and conduct basic nursing procedures. 4 Figure 5.21 and Table 5.21 summarize the state and county trends for Arizona licensed CNAs in the state from 2002 to There were 20,518 CNAs in Arizona in State wide there was as 12% increase in number of CNAs (+2,196) from 2002 to 2007 but a decrease in Figure Licensed Practical Nurse (LPN) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure Licensed Practical Nurses (LPNs) per 100,000 Population Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: Source: Arizona Board of Nursing Licensed Practical Nurses File Figure Licensed Practical Nurse (LPN) Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Nursing Licensed Practical Nurses File Population estimates provided by the U.S. Census Bureau. Figure Licensed Practical Nurses (LPNs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Nursing Licensed Practical Nurses File 2008 Source: Arizona Board of Nursing Licensed Practical Nurses File Population estimates provided by Claritas. 5-6

53 CAN-population ratios from 336 per 100,000 in 2002 to 324 per 100,000 in 2007 (Figure 5.22 and Table 5.22). Decreases occurred in the urban classified counties (from 315 to 293 per 100,000) and the rural-rural classified counties (from 426 to 422 per 100,000). The CNA-population ratios increase in the rural-urban classified counties from 350 to 428 per 100,000. The county rankings of CNA-population ratios in 2007 are presented in Map 5.6. The counties with the largest CNA-population ratios in 2007 were Graham (863 per 100,000), Gila (731 per 100,000) and Greenlee (529 per 100,000) counties. The counties with the smallest CNA-population ratios were La Paz (129 per 100,000), Maricopa (284 per 100,000) and Pima (328 per 100,000) counties. The rural-urban classified counties increased 36% (+358) from 2002 to 2007, urban classified counties increased 8% (+1,054), and rural-rural classified counties increased 19% (+784). The number of CNAs decreased 37% (-15) in La Paz County and increased 2% in Apache County (+6) and 29% in Maricopa County (+917) during the six-year period. The 2002 to 2007 trends in number of CNAs and number of CNAs per 100,000 population for the four RUCA categories are shown in Figures 5.23 and The number of CNAs increased 35% (+382) in the small rural town areas, and 17% (+302) in the large rural town areas (Table 5.23). In 2007 large rural town areas had 474 Map 5.6. Certified Nurse Assistants- Population Ratios by Arizona Counties for 2007 Source: Arizona Nursing Board CNAs per 100,000 population and small rural town areas had 382 per 100,000. The six-year trends are presented in Table Figure Certified Nurse Assistant (CNA) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure Certified Nurse Assistants (CNAs) per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: Source: Arizona Board of Nursing, Certified Nurse Assistants File Figure Certified Nurse Assistant (CNA) Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Nursing, Certified Nurse Assistants File Population estimates provided by the U.S. Census Bureau. Figure Certified Nurse Assistants (CNAs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Source: Arizona Board of Nursing, Certified Nurse Assistants File Source: Arizona Board of Nursing, Certified Nurse Assistants File Population estimates provided by Claritas. 5-7

54 5.1 Nursing Practice Profile Based on responses to licensing renewal questionnaires conducted by the Arizona Board of Nursing in 2007 and 2008, approximately 85.2 percent of RNs were employed in an occupation that required a nursing license and nearly 85 percent reported that they provided direct patient care. Approximately 93.5 percent of advanced practice nurses (nurse practitioners, certified nurse anesthetists, clinical nurse specialists, certified nurse midwives) reported working in direct patient care. Approximately 76 percent of the advanced practice nurses worked at least 36 hours per week. Approximately 33 percent of clinical practice LPNs worked in geriatrics compared to 4.5 percent for RNs. Approximately 13 percent of LPNs worked in generalized community health and 11 percent in the medical/surgical area. The majority of new LPNs came from one of the Arizona LPN programs (East Valley Institute of Technology, Estrella Mountain Community College Southwest Skill Center, Gateway Community College, Maricopa Skill Center, and Pima Community College) or from RN programs that allowed students to work as an LPN while completing their RN degree Summary Of the four major nursing categories (registered nurses, nurse practitioners, licensed practical nurses, and certified nurse assistants), registered nurses were the most numerous (52,395 in 2007) followed by certified nurse assistants (20,518). The number RNs and number of RNs per 100,000 population increased in all three county-ruralness categories from 2002 to Noticable inequalities in the distribution of RNs occurred between ruralness categories. The state wide number of registered nurses per 100,000 peaked in 2004 (853) and decreased to 827 per 100,000 in The largest number of certified registered nurse anesthetists (78.9%) was located in the urban classified counties in The number of NPs increased 52% (+782) from 2002 to 2007 (2,294) in Arizona. The NP-population ratios increased state wide from 28 to 36 per 100,000 from 2002 and 2007 and also increased in all three county ruralness categories. There were no nurse practitioners reported in Greenlee County from 2002 to Wide inequalities in the distribution of NPpopulation ratios were apparent between the urban and rural areas from 2002 to From 2002 to 2007 the number of certified nurse midwives increased from 140 in 2002 to 156 in 2007 (+16). The CNM-population ratios decreased in ruralrural classified counties from 2002 to No CNMs were reported in Greenlee, La Paz, Gila and Cochise counties in There were 2.2 times more CNAs (20,518) than LPNs (9,241) in Both CNAs and LPNs gained about the same number of practitioners from 2002 and 2007 (LPN: +2,238 and CNA: +2,196). In 2007, large rural town areas had greater number of LPNs per 100,000 population than the urban areas. There were more CNAs per 100,000 population in the rural areas than urban areas. 5.3 References 1. Gordon, R. J. (1987). Arizona Rural Health Provider Atlas, Rural Health Office, Department of Family and Community Medicine, University of Arizona College of Medicine. pp The New York Center for Health Workforce Studies (2006). The United States Workforce Profile, Health Resources and Services Administration, DHHS. pp The Center for Health Information & Research (CHIR) (2009). The Arizona Health Care Workforce: Nurses, Pharmacists, & Physician Assistant. pp Wikipedia, Certified Nursing Assistant (2010). Retrieved on March 30, 2010 on the World Wide Web: Nursing_Assistant. 5. Johnson WG, Wilson B, Edge M, Qiu Y, Oliver EL, and Russell K The Arizona Health Care Workforce: Nurses, Pharmacists, & Physician Assistants. Center for Health Information and Research, Arizona State University, Tempe. pp

55 Table 5.1. Registered Nurses (RNs): Arizona County Changes between 2002 and 2007 County Number in 2002 Number in 2007 Net Change from Percent Change from 2002 to to 2007 Apache % Cochise % Coconino 1,133 1, % Gila % Graham % Greenlee % La Paz % Maricopa 27,649 32,487 4,838 17% Mohave 1,122 1, % Navajo % Pima 8,521 9,527 1,006 12% Pinal 1,116 1, % Santa Cruz % Yavapai 1,811 2, % Yuma 820 1, % Arizona - Total 44,506 52,395 7,889 18% Urban Counties 36,170 42,014 5,844 16% Rural-Urban Counties 1,953 2, % Rural-Rural Counties 6,383 7,951 1,568 25% Source: Arizona Board of Nursing, Registered Nurses File Table 5.2. Registered Nurses (RNs) per 100,000 Population: Arizona County Changes between 2002 and 2007 County Apache Cochise Coconino 941 1,016 1,059 1,058 1,053 1,087 Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima 971 1,002 1,022 1, Pinal Santa Cruz Yavapai 1,015 1,035 1,043 1, Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Source: Arizona Board of Nursing, Registered Nurses File Population estimates provided by the U.S. Census Bureau. 5-9

56 Table 5.3. Registered Nurses (RNs): Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Arizona - Total 44,506 52,395 7,889 18% Urban 39,661 46,796 7,135 18% Large Rural Town 2,617 3, % Small Rural Town 1,836 2, % Isolated Small Rural Town % Source: Arizona Board of Nursing, Registered Nurses File Table 5.4. Registered Nurses (RNs) per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Source: Arizona Board of Nursing,Registered Nurses File Population estimates provided by Nielsen-Claritas. Table 5.5. Certified Registered Nurse Anesthetist (CRNAs): Arizona County Changes between 2002 and 2007 County Number in 2002 Number in 2007 Net Change from Percent Change from 2002 to to 2007 Apache NA Cochise % Coconino % Gila % Graham % Greenlee NA La Paz % Maricopa % Mohave % Navajo % Pima % Pinal % Santa Cruz NA Yavapai % Yuma NA Arizona Total % Urban Counties % Rural-Urban Counties % Rural-Rural Counties % Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File

57 Table 5.6. Certified Registered Nurse Anesthetist (CRNAs) per 100,000 Population: Arizona County Changes between 2002 and 2007 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File Population estimates provided by the U.S. Census Bureau. Table 5.7. Certified Registered Nurse Anesthetist (CRNAs): Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Arizona Total % Urban % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File Table 5.8. Certified Registered Nurse Anesthetist (CRNAs) per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File Population estimates provided by Nielsen-Claritas. 5-11

58 Table 5.9. Nurse Practitioners (NPs): Arizona County Changes between 2002 and 2007 County Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Apache % Cochise % Coconino % Gila % Graham % Greenlee NA La Paz % Maricopa 916 1, % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona - Total 1,512 2, % Urban Counties 1,256 1, % Rural-Urban Counties % Rural-Rural Counties % Source: Arizona Board of Nursing, Nurse Practitioners File Table Nurse Practitioners (NPs) per 100,000 Population: Arizona County Changes between 2002 and 2007 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Source: Arizona Board of Nursing, Nurse Practitioners File Population estimates provided by the U.S. Census Bureau. 5-12

59 Table Nurse Practitioners (NPs): Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Arizona Total 1,512 2, % Urban 1,372 2, % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Source: Arizona Board of Nursing, Nurse Practitioners File Table Nurse Practitioners (NPs) per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Source: Arizona Board of Nursing, Nurse Practitioners File Population estimates provided by Nielsen-Claritas. Table Certified Nurse Midwives (CNMs): Arizona County Changes Between 2002 and 2007 County Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Apache % Cochise % Coconino % Gila NA Graham % Greenlee NA La Paz NA Maricopa % Mohave % Navajo % Pima % Pinal % Santa Cruz NA Yavapai % Yuma % Arizona Total % Urban Counties % Rural-Urban Counties % Rural-Rural Counties % Source: Arizona Board of Nursing, Certified Midwives File

60 Table Certified Nurse Midwives (CNMs) per 100,000 Women of Child Bearing Age (15 44 y/o): Arizona County Changes Between 2002 and 2007 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Source: Arizona Board of Nursing, Certified Nurse Midwives File Population estimates provided by the U.S. Census Bureau Table Certified Nurse Midwives (CNMs): Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 RUCA Number in 2002 Number in 2007 Arizona Total % Urban % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Source: Arizona Board of Nursing, Certified Nurse Midwives File Table Certified Nurse Midwives (CNMs) per 100,000 Women of Child Bearing Age: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Source: Arizona Board of Nursing, Certified Nurse Midwives File Population estimates provided by Nielsen-Claritas. 5-14

61 Table Licensed Practical Nurses (LPNs): Arizona County Changes between 2002 and 2007 County Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 4,065 5,535 1,470 36% Mohave % Navajo % Pima 1,482 1, % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 7,003 9,241 2,238 32% Urban Counties 5,547 7,340 1,793 32% Rural-Urban Counties % Rural-Rural Counties 1,258 1, % Source: Arizona Board of Nursing Licensed Practical Nurses File Table Licensed Practical Nurses (LPNs) per 100,000 Population: Arizona County Changes between 2002 and 2007 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Source: Arizona Board of Nursing Licensed Practical Nurses File Population estimates provided by the U.S. Census Bureau. 5-15

62 Table Licensed Practical Nurses (LPNs): Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Arizona Total 7,003 9,241 2,238 32% Urban 6,067 8,099 2,032 33% Large Rural Town % Small Rural Town % Isolated Small Rural Town % Source: Arizona Board of Nursing Licensed Practical Nurses File Table Licensed Practical Nurses (LPNs) per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Source: Arizona Board of Nursing Licensed Practical Nurses File Population estimates provided by Claritas. Table Certified Nurse Assistants (CNAs): Arizona County Changes Between 2002 and 2007 County Number in 2002 Number in 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 10,114 11, % Mohave % Navajo % Pima 3,034 3, % Pinal 916 1, % Santa Cruz % Yavapai % Yuma % Arizona Total 18,322 20,518 2,196 12% Urban Counties 13,148 14,202 1,054 8% Rural-Urban Counties 1,004 1, % Rural-Rural Counties 4,170 4, % Source: Arizona Board of Nursing, Certified Nurse Assistants File

63 Table Certified Nurse Assistants (CNAs) per 100,000 Population: Arizona County Changes Between 2002 and 2007 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Source: Arizona Board of Nursing, Certified Nurse Assistants File Population estimates provided by the U.S. Census Bureau. Table Certified Nurse Assistants (CNAs): Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Net Change from 2002 to 2007 Percent Change from 2002 to 2007 RUCA Number in 2002 Number in 2007 Arizona Total 18,322 20,518 2,196 12% Urban 15,138 16,640 1,502 10% Large Rural Town 1,751 2, % Small Rural Town 1,094 1, % Isolated Small Rural Town % Source: Arizona Board of Nursing, Certified Nurse Assistants File Table Certified Nurse Assistants (CNAs) per 100,000: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Source: Arizona Board of Nursing, Certified Nurse Assistants File Population estimates provided by Nielsen-Claritas. 5-17

64

65 SECTION 6: DENTISTS Total Arizona Dentists: Dentists are the primary providers of dental care. They promote the prevention of disease, and diagnose and treat oral diseases of the teeth and supporting structures. 1 Arizona Department of Health Services (ADHS) provided dentist data from 2002 to 2006 and was analyzed for this study. This data was collected by the Arizona Board of Dental Examiners and unlike data from the other Arizona licensing boards, this data included multiple practice locations if reported by each dentist. Dentists in this data were assigned a pseudo full-time equivalent (FTE) value that was based on the number of practice locations each dentist had for each year. This pseudo-fte was proportional to the number of practice locations reported. For example, if a dentist worked in only one location then a FTE of 1.0 was assigned, if two locations were reported for a dentist then that dentist was assigned 0.5 FTE for each location, if three locations were reported for a dentist then 0.33 FTE were assigned for each location, etc. In 2006, 61 percent of Arizona dentists practiced in one office location (Table 6.1). The percentage of dentists practicing in one office location had decreased between 2002 and 2006 (67% in 2002 to 61% in 2006). One fourth of the dentists practiced in two locations in The workforce count and relative counts are reported by this pseudo- FTE. Dentists were classified as primary care dentists unless they reported a specialty. The New York Center for Health Workforce Studies reported that Arizona was ranked 22nd nationally based on number of dentists per 100,000 population in According to this study Arizona had 51.8 dentists per 100,000 population and was less that the U.S. average of 59.4 per 100, This national study used data from the Kaiser Family Foundation and the American Dental Association and reported a slightly larger coverage of dentists than analysis of the 2004 Arizona Board of Dental Examiner data showed (50.2 dentists per 100,000). In 2006, there were 3,316 active licensed dentists in the state. There was an increase of 730 dentists (28%) from 2002 to 2006 (Figure 6.1 and Table 6.2). During the same period, there was an increase in dentistpopulation ratios from 47 per 100,000 in 2002 to 54 per 100,000 in 2006 (Figure 6.2 and Table 6.3). The dentist-population ratios increased in all three county ruralness categories: from 52 to 59 per 100,000 in urban counties, from 38 to 42 per 100,000 in ruralurban counties, and from 33 to 37 per 100,000 in rural-rural counties. The county rankings of dentist-population ratios in 2006 are presented in Map 6.1. The three counties with the largest dentist-population ratios in 2006 were Coconino (62 per 100,000), Maricopa (60 per 100,000), and Yavapai (60 per 100,000) counties while the smallest were La Paz (15 per 100,000), Greenlee (20 per 100,000), and Santa Cruz (21 per 100,000) counties. Map 6.1. Dentists- Population Ratios by Arizona Counties for 2006 Source: ADHS Figure 6.1. Total Dentist Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: Figure 6.2. Total Dentists per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by the U.S. Census Bureau. 6-1

66 From 2002 to 2006 the greatest increase in number (pseudo-ftes) of dentists by ruralness occurred in the rural-rural classified counties (30%), followed by the urban classified counties (28%), and the rural-urban classified counties (18%). The largest percentage increase by county occurred in Pinal (69%), La Paz (50%), and Apache (46%) counties. The largest increases in number (pseudo-ftes) of dentists by county occurred in the urban classified counties (Maricopa and Pima counties). Greenlee County decreased in the number (pseudo-ftes) of dentists (-0.67 FTE). The trends in number of dentists and dentistpopulation ratios for the four rural-urban commuting areas (RUCA) categories from 2002 to 2006 are shown in Figures 6.3 and 6.4. The urban areas had the greatest increases in number of dentists (29%), followed by the large rural town areas (24%), then followed by small rural town areas (19%) (Table 6.4). The inequalities in distribution of dentist-population ratios by ruralness were noticeable from 2002 to In 2006 there were 58 dentists per 100,000 in the urban areas, 39 per 100,000 in the large rural town areas, 36 per 100,000 in the small rural town areas, and 21 per 100,000 in the isolated small rural town areas (Table 6.5 ). General Dentists: Of the 3,316 Arizona licensed dentists in the state in 2006, 81 percent (2,693) were general dentists. The number of general dentist state wide increased 24 percent (+529) between 2002 and 2006 (Figure 6.5). The largest percent increase by county ruralness classification was in the rural-rural classified counties (29%) (Table 6.6). Greenlee County was the only county in the state that decreased in the number of general dentists. The two urban classified counties had the greatest increase in number of general dentist (+436). From 2002 to 2006 the state wide general dentist- Figure 6.3. Total Dentist Profile for Arizona s Four Rural Urban Commuting Areas: Figure 6.4. Total Dentist per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Figure 6.5. General Dentist Profile for Arizona and Urban/ Rural- Urban/Rural-Rural Counties: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by Claritas. Figure 6.6. General Dentists per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by the U.S. Census Bureau.

67 population ratio increased from 40 to 44 per 100,000 (Figure 6.6 and Table 6.7). The number of general dentists per 100,000 population increased in the three county ruralness categories but the inequality remained between urban classified counties, the rural-urban classified counties, and rural-rural classified counties. The 2006 county rankings for the general dentistpopulation ratios are shown in Map 6.2. The three counties with the largest dentist-population ratios in 2006 were Yavapai (52 per 100,000) Coconino (48 per 100,000), and Maricopa (48 per 100,000) counties. The smallest dentist-population ratios were La Paz (12 per 100,000), Greenlee (20 per 100,000), Apache (21 per 100,000) and Santa Cruz (21 per 100,000) counties. Figures 6.7 and 6.8 show the trends of general dentist numbers and dentist-population ratios for the four RUCA categories from 2002 to The RUCA categories show a wider distribution of ruralness inequality (Figure 6.8) than the county ruralness classification (Figure 6.6). The trends based on RUCA categories are also presented in Tables 6.8 and 6.9. Dentist Specialists: In 2006, there were 623 specialist dentists in the state. There was a 48 percent increase (+201) in number of specialist dentists from 2002 to 2006 (Figure 6.9 and Table 6.10). Most (86%) of the specialist dentists practiced in the urban classified counties. State wide the number of specialist dentists per 100,000 population increased for 8 in Map 6.2. General Dentists-Population Ratios by Arizona Counties for 2006 Source: ADHS Figure 6.7. General Dentist Profile for Arizona s Four Rural Urban Commuting Areas: Figure 6.8. General Dentist per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Figure 6.9. Specialist Dentist Profile for Arizona and Urban/ Rural- Urban/Rural-Rural Counties: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by Claritas. Figure Specialist Dentists per 100,000 Population Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by the U.S. Census Bureau. 6-3

68 2002 to 10 in 2006 (Figure 6.10 and Table 6.11). The specialist-population ratios increases in the three county ruralness classifications: urban classification increased from 9 to 11 per 100,000; rural-urban classification increased from 7 to 9 per 100,000; and rural-rural classification increased from 4 to 5 per 100,000. The 2006 county rankings by specialist-population ratios are presented in Map 6.3. The three counties with the largest specialist-population ratios in 2006 were Coconino (14 per 100,000), Maricopa (12 per 100,000), and Pima (10 per 100,000) counties. The smallest specialist-population ratios were Greenlee (0), Santa Cruz (0), and La Paz (2 per 100,000) counties. per 100,000). 3 However an area with unusually high needs for dental services or insufficient capacity of existing dental providers can have a ratio of 4,000:1 (25 dentist per 100,000). Map 6.4 shows the 2009 Dental HPSA designations in Arizona and corresponds with this study s dentist-population ratios at the county level (Table 6.3). 6.1 Dentist Practice Profile Map 6.3. Dentist Specialists- Population Ratios by Arizona Counties for 2006 Source: ADHS The trends of number of specialist dentists and specialist-population ratios for the four RUCA categories from 2002 to 2006 are shown in Figures 6.11 and The urban areas had the 49 percent increase in number of specialist dentists, followed by a 39 percent increase in number of specialist in the large rural town areas, followed by a 24 percent increase in specialists in the small rural town areas (Table 6.12). Isolated small rural town areas decreased from 2 to 1 specialist dentist. The inequality in distribution of specialist density by ruralness is apparent in the specialist-population ratio trends (Figure 6.12 and Table 6.13). In 2006, 92.3 percent (575) of specialist dentists practiced in the urban areas and only one (1) specialist dentist practiced in the isolated small rural town areas. Health Resources and Services Administration has defined a dental health profession shortage area (HPSA) as an area that has a population to full-time equivalent dentist ratio of at least 5,000:1 (20 dentist Based on a 2000 to 2001 telephone survey of licensed and practicing dentists conducted by the Arizona Department of Health Services Office of Oral Health, general practice dentists in Arizona worked an average of 36 hours per week and saw an average of 54 patients. Specialist dentists worked an average of 37 hours per week and saw an average of 103 patients. Approximately 19 percent of the dentists surveyed accepted AHCCCS patients. Approximately 74 percent of dentists had solo practices and employed dental assistants at an average of 2.6 FTE and dental hygienists at an average of 1.5 FTE (FTE = 32 hours per week) Summary In 2006, 3,316 dentists had active Arizona licenses and reported an Arizona residence or practice address. The number of dentists in the state increased 28 percent (+730) from 2002 to Eighty-three percent of active license dentists were located in Maricopa and Figure Specialist Dentist Profile for Arizona s Four Rural Urban Commuting Areas: Figure Specialist Dentists per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by Claritas.

69 Map 6.4. Arizona Dental HPSA Designation: April 2009 specialist dentists by ruralness occurred from 2002 to 2006 with the smaller dentist-population ratios occurring in the more rural categories. There were four times as many active licensed general dentists than dentist specialists in During the five-year period from 2002 to 2006, the number of specialist dentists increased 48 percent and the number of general dentists increased 24 percent. 6.3 References 1. Gordon, R. J. (1987). Arizona Rural Health Provider Atlas, Rural Health Office, Department of Family and Community Medicine, University of Arizona College of Medicine. pp Source: ADHS Pima counties. Three rural-rural classified counties (La Paz, Greenlee, and Santa Cruz counties) had the smallest number of dentists in the state. The state wide dentist-population ratio was 54 per 100,000 in 2006, an increase from 47 per 100,000 in The counties with the largest dentist-population ratios were Coconino, Maricopa, and Pima. The smallest dentist-population ratios occurred in La Paz, Greenlee, and Santa Cruz counties. Inequalities in the distribution of population ratios for all, general, and 2. The New York Center for Health Workforce Studies (2006). The United States Workforce Profile, Health Resources and Services Administration, DHHS. pp Health Resources and Services Administration, Bureau of Health Professionals, Dental HSPA Designation Overview. (2009) Retrieved on October 29, 2010 from htm. 4. Mertz E, and Grumbach K The Distribution and Composition of Arizona s Dental Workforce and Practice Patterns: Implications for Access to Care. Center for California Health Workforce Studies, University of California San Francisco. 6-5

70 Table 6.1. Number of Office Locations per Dentist in Arizona: Year Total ,718 67% % 182 7% 74 3% 2, ,767 65% % 187 7% 97 4% 2, ,855 64% % 225 8% 119 4% 2, ,979 63% % 251 8% 138 4% 3, ,014 61% % 279 8% 178 5% 3,312 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Table 6.2. Total Dentists: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 1, , % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 2, , % Urban Counties 2, , % Rural-Urban Counties % Rural-Rural Counties % Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files,

71 Table 6.3. Total Dentists per 100,000 Population: Arizona County Changes between County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by the U.S. Census Bureau. Table 6.4. Total Dentists: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Arizona Total 2,586 3, % Urban 2,317 2, % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Table 6.5. Total Dentists per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by Nielsen-Claritas. 6-7

72 Table 6.6. General Dentists: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 1, , % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 2, , % Urban Counties 1, , % Rural-Urban Counties % Rural-Rural Counties % Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Table 6.7. General Dentists per 100,000 Population: Arizona County Changes between County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by the U.S. Census Bureau. 6-8

73 Table 6.8. General Dentists: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Arizona Total 2,164 2, % Urban 1,932 2, % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Table 6.9. General Dentists per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by Nielsen-Claritas. Table Dentist Specialists: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee NA La Paz NA Maricopa % Mohave % Navajo % Pima % Pinal % Santa Cruz NA Yavapai % Yuma % Arizona Total % Urban Counties % Rural-Urban Counties % Rural-Rural Counties % Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files,

74 Table Dentist Specialists per 100,000 Population: Arizona County Changes between 2002 and 2006 County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona - Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by the U.S. Census Bureau. Table Dentist Specialists: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Number in 2002 Number in 2006 Net Change from 2002 to 2006 Percent Change from 2002 to 2006 Arizona Total % Urban % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Table Dentist Specialists per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, Population estimates provided by Nielsen-Claritas. 6-10

75 SECTION 7: PHARMACISTS AND PHARMACY TECHNICIANS Pharmacists: Pharmacists are recognized as medication experts in the health field and are the primary dispensers of prescription drugs that are used for the curing, preventing, eliminating, and diagnosing of diseases. They promote the appropriate use of both prescription and over-the-counter drugs. Most pharmacists are employed in the community setting. State wide there were 5,309 active Arizona licensed pharmacists in There was a 47 percent increase of pharmacists (+1,691) between 2002 and 2007 (Figure 7-1 and Table 7-1). The data used in this study was collected by the Arizona State Board of Pharmacy. The New York Center for Health Workforce Studies ranked Arizona 46 th nationally in 2004 by numbers of pharmacists per 100,000 population. 1 Arizona s 66.7 pharmacists per 100,000 population was less than the U.S. average of 77.0 per 100, This national study used data from the Bureau of Labor Statistics Occupational Employment Statistics. Arizona s pharmacist-population ratios increased from 66 per 100,000 in 2002 to 84 per 100,000 in 2007 (Figure 7.2 and Table 7.2). An increase occurred in all three county ruralness classification; urban classified counties increased from 75 to 96 per 100,000, ruralurban classified counties increased from 39 to 48 per 100,000, and rural-rural classified counties increased from 38 to 45 per 100,000. The largest increase was in the two urban classified counties. The 2007 county rankings of pharmacist-population ratios are presented in Map 7.1. The three counties with the largest pharmacist-population ratios were Pima (100 per 100,000), Maricopa (94), and Coconino (71) counties. The smallest were Greenlee (0), La Paz (5 per 100,000) and Apache (11 per 100,000) counties. Map 7.1. Pharmacists -Population Ratios by Arizona Counties for 2007 During the period from 2002 to 2007, the number of pharmacists increased 48 percent (+1,501) in the urban classified counties. The number of pharmacists in Maricopa County increased Source: AZ Pharmacy Board 53 percent (+1,265) and increased 32 percent (+236) in Pima County. The number of pharmacists increased 36 percent (+41) in the ruralurban classified counties and increased 40 percent (+149) in rural-rural classified counties. There were no changes in the number of pharmacists in Greenlee (0) and La Paz (1) Counties from 2002 to The number of pharmacists decreased by one in Apache County (from 9 to 8). The remaining counties increased in the number of pharmacists over the sixyear period. The 2002 to 2007 trends in number of pharmacist and pharmacist-population ratios for the four rural-urban commuting areas (RUCA) categories are shown in Figures 7.3 and 7.4. The number of pharmacists increased 48 percent in the urban areas, 40 percent in the large rural town areas, and 25 percent in the small isolated rural town areas (Table 7.3). Inequities are apparent in the distribution of pharmacists per Figure 7.1. Pharmacist Profile for Arizona and Urban/ Rural- Urban/Rural-Rural Counties: Figure 7.2. Pharmacists per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Sources: Arizona State Board of Pharmacy, Pharmacist Files Sources: Arizona State Board of Pharmacy, Pharmacist Files Population estimates provided by the U.S. Census Bureau. 7-1

76 100,000 population by ruralness categories. In 2007 there were 94 pharmacists per 100,000 population in the urban areas, 50 per 100,000 in large rural town areas, 29 per 100,000 in small rural town areas, and 23 per 100,000 in isolated small rural town areas. Table 7.4 shows the six year trends. Pharmacy Technicians: The Arizona Board of Pharmacy began the certification of pharmacy technicians in Technicians may carry out certain pharmacist functions under the supervision of a pharmacist. From 2004 to 2007 the number of pharmacy technicians increased 105 percent, from 3,375 to 6,905 (Figure 7.5). There were more certified pharmacy technicians than licensed pharmacists (5,309) in the state in The number of pharmacy technicians increased 131 percent (+106) in the rural-urban classified counties, 110 percent (+518) in the rural-rural classified counties, and 103 percent (+2,906) in the urban classified counties (Table 7.5). The New York Center for Health Workforce Studies reported that Arizona was ranked 24 th nationally in the number of pharmacy technicians per 100,000 population in Arizona s pharmacy technicians per 100,000 population was less than the U.S. average of per 100, This national study used data from the Bureau of Labor Statistics Occupational Employment Statistics. Based on Arizona Board of Pharmacy data, the ratio of Arizona pharmacy technicians per 100,000 population increased from 59 in 2004 to 109 in 2007 (Figure 7.6 and Table 7.6). The pharmacy technicians per 100,000 population increased in all of the three county ruralness classifications. The inequality of the distribution of pharmacy technicians by ruralness is illustrated by the 2002 to 2007 trends (Figure 7.6) and demonstrated by the widely spaced 2007 population ratios (118 pharmacy technicians per 100,000 in urban classified counties, 59 per 100,000 in the rural-urban classified counties, and 84 per 100,000 in the ruralrural classified counties). The 2007 county rankings of pharmacy technicians-population ratios are shown in Map 7.2. The three counties with the largest pharmacy technician-population ratios were Pinal (131 per 100,000), Maricopa (123 per 100,000), and Graham (104 per 100,000) counties. The counties with the smallest pharmacy technician-population ratios were Greenlee (13 per 100,000), La Paz (25 per 100,000) and Apache (39 per 100,000) counties. Figures 7.7 and 7.8 show the 2004 to 2007 trends of pharmacy technician numbers and pharmacy technician-population ratios by four RUCA categories. The number of pharmacy technician increased 110 percent in the large rural town areas, 104 percent in the urban areas, and 100 percent in the small rural town areas (Table 7.7). The inequality of the distribution of pharmacy technicians by ruralness is apparent in the 2002 to 2007 trends using RUCA categories (Figure 7.8). In 2007, the pharmacy technicianpopulation ratios were 119 per 100,000 in the urban areas, 86 per 100,000 in the large rural town areas, 53 per 100,000 in the small rural town areas and 27 per 100,000 in the isolated small rural town areas. Table 7.8 shows the four year trends. Map 7.2. Pharmacy Technicians-Population Ratios by Arizona Counties for 2007 Source: AZ Pharmacy Board Figure 7.3. Pharmacist Profile for Arizona s Four Rural Urban Commuting Areas: Figure 7.4. Pharmacists per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona State Board of Pharmacy, Pharmacist Files Sources: Arizona State Board of Pharmacy, Pharmacist Files Population estimates provided by Claritas.

77 Figure 7.5. Pharmacy Technician Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 7.6. Pharmacy Technicians per 100,000 Population Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: Sources: Arizona State Board of Pharmacy, Pharmacist Files Figure 7.7. Pharmacy Technician Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona State Board of Pharmacy, Pharmacist Files Population estimates provided by the U.S. Census Bureau. Figure 7.8. Pharmacy Technicians per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona State Board of Pharmacy, Pharmacist Files Sources: Arizona State Board of Pharmacy, Pharmacist Files Population estimates provided by Claritas. 7.1 Pharmacists and Pharmacy Technician Practice Profiles The Center for Health Information and Research (CHiR) estimated that approximately 33 percent of pharmacists in Arizona had less than 5 years of experience, 26 percent had Pharm. D. degrees, 50 percent were female, 52 percent worked for retail chain pharmacies, 18 percent worked for hospitals, 4 percent were unemployed, and approximately 67 percent worked full-time. 2 The CHiR also estimated that approximately 64 percent of pharmacy technicians in Arizona worked for retail chain pharmacies, 77 percent were female, 36 percent were 25 to 35 years of age, and approximately 55 percent worked full-time Summary In 2007, there were 5,309 active licensed pharmacists in Arizona. From 2002 to 2007 the number of pharmacists in the state increased 47 percent (+1,691). Eighty-seven percent of active licensed pharmacists were located in Maricopa and Pima counties. Three rural-rural classified counties (Greenlee, La Paz, and Apache) had the smallest number of pharmacists in the state. There was an increase in the state wide pharmacistpopulation ratios from 66 per 100,000 in 2002 to 84 per 100,000 in The largest pharmacistspopulation ratios occurred in Pima, Maricopa, and Coconino counties. The smallest ratios occurred in three rural-rural classified counties (Greenlee, La Paz, and Apache counties). 7-3

78 In 2007, there was more certified pharmacy technicians (6,905) than licensed pharmacists (5,309) in Arizona. The number of pharmacy technicians increased 105 percent (+3,530) from 2004 to Similar to the spatial distribution of pharmacists, most of the pharmacist technicians are located in Maricopa and Pima counties (83%). Pharmacy technicians have a higher population ratios than pharmacists (109 pharmacy technician per 100,000 versus 84 pharmacists per 100,000 state wide). Greenlee, La Paz, and Apache counties had the smallest number and pharmacy technician-population ratios among Arizona s counties. The pharmacist and pharmacy technician distribution inequalities were apparent between urban and rural areas. 7.3 References 1. The New York Center for Health Workforce Studies (2006). The United States Workforce Profile, Health Resources and Services Administration, DHHS. pp The Center for Health Information & Research (CHIR) (2009). The Arizona Health Care Workforce: Nurses, Pharmacists, & Physician Assistant. pp

79 Table 7.1. Pharmacists: Arizona County Changes between 2002 and 2007 County Number in 2002 Number in 2007 Net Change from Percent Change from 2002 to to 2007 Apache % Cochise % Coconino % Gila % Graham % Greenlee NA La Paz % Maricopa 2,400 3,665 1,265 53% Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 3,618 5,309 1,691 47% Urban Counties 3,131 4,632 1,501 48% Rural-Urban Counties % Rural-Rural Counties % Sources: Arizona State Board of Pharmacy, Pharmacist Files Table 7.2. Pharmacists per 100,000 Population: Arizona County Changes between County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona State Board of Pharmacy, Pharmacist Files Population estimates provided by the U.S. Census Bureau. 7-5

80 Table 7.3. Pharmacists: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Number in 2002 Number in 2007 Net Change from Percent Change 2002 to 2007 from 2002 to 2007 Arizona Total 3,618 5,309 1,691 47% Urban 3,354 4,957 1,603 48% Large Rural Town % Small Rural Town % Isolated Small Rural Town % Sources: Arizona State Board of Pharmacy, Pharmacist Files Table 7.4. Pharmacists per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona State Board of Pharmacy, Pharmacist Files Population estimates provided by Nielsen-Claritas. Table 7.5. Pharmacy Technicians: Arizona County Changes between 2004 and 2007 County Number in 2004 Number in 2007 Net Change from Percent Change from 2004 to to 2007 Apache % Cochise % Coconino % Gila % Graham % Greenlee NA La Paz % Maricopa 2,292 4,758 2, % Mohave % Navajo % Pima % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 3,375 6,905 3, % Urban Counties 2,825 5,731 2, % Rural-Urban Counties % Rural-Rural Counties % Sources: Arizona State Board of Pharmacy, Pharmacy Technician Files

81 Table 7.6. Pharmacy Technicians per 100,000 Population: Arizona County Changes between County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona State Board of Pharmacy, Pharmacy Technician Files Population estimates provided by the U.S. Census Bureau. Table 7.7. Pharmacy Technicians: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2004 and 2007 RUCA Number in 2004 Number in 2007 Net Change from Percent Change 2004 to 2007 from 2004 to 2007 Arizona Total 3,375 6,905 3, % Urban 3,080 6,298 3, % Large Rural Town % Small Rural Town % Isolated Small Rural Town % Sources: Arizona State Board of Pharmacy, Pharmacy Technician Files Table 7.8. Pharmacy Technicians per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2004 and 2007 RUCA Arizona Total Urban Large Rural Town Small Rural Town Isolated Small Rural Town Sources: Arizona State Board of Pharmacy, Pharmacy Technician Files Population estimates provided by Nielsen-Claritas. 7-7

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83 SECTION 8: EMERGENCY MEDICAL TECHNICIANS The Bureau of Emergency Medical Services & Trauma System, Arizona Department of Health Services (ADHS), certifies all levels of emergency medical technicians (EMT-Basic, EMT-Intermediate, and EMT-Paramedic). The 2002 to 2006 dataset that was provided by ADHS did not include unique identifiers such as names or certification numbers to remove duplicate records or impute missing EMTs. In 2006, there were 15,032 certified emergency medical technicians (EMT) in Arizona. From 2002 to 2006 there was a 25 percent (+3,049) increase in EMTs (Figure 8.1 and Table 8.1). The number of EMTs increased 27 percent (+2,232) in the urban classified counties, 21 percent (+200) in the rural-urban classified counties, and 21 percent (+617) in the ruralrural classified counties. The New York Center for Health Workforce Studies reported that Arizona was ranked 45th nationally for number of emergency medical technicians per 100,000 population in Arizona s 38.1 EMTs per 100,000 population was less than the U.S. average of 65.1 per 100, This national study used data from the Bureau of Labor Statistics Occupational Employment Statistics and estimated a much smaller 2004 ratio than reported by ADHS data (226 EMTs per 100,000 population in Arizona). The report by New York Center for Health Workforce Studies did not provide sufficient information to indicate the reason for the difference between their report 1 and the ADHS data. Reporting different certification levels may explain the different estimates. From 2002 to 2006, the number of EMTs increased from 220 per 100,000 population to 244 per 100,000 (Figure 8.2 and Table 8.2). The urban classified counties increased from 195 to 219 per 100,000, rural-urban classified counties increased from 332 to 369 per 100,000, and rural-rural classified counties increased 296 to 313 per 100,000. The 2006 county rankings of EMT-population ratios are presented in Map 8.1. The three counties with the largest EMT-population Map 8.1. Emergency Medical Technicians- Population Ratios by Arizona Counties for 200 Source: ADHS ratios in 2006 were Coconino (552 per 100,000), Gila (515 per 100,000), and Greenlee (402 per 100,000) counties. The three counties with the smallest EMTpopulation ratios were Apache (164 per 100,000), Maricopa (206 per 100,000), and Pinal (235 per 100,000) counties. Figures 8.3 and 8.4 show the 2002 to 2006 trends for number of EMTs and number of EMTs per 100,000 by four rural-urban commuting area (RUCA) categories. The number of EMTs increased 29 percent in the urban areas, 14 percent in the large rural town areas, and 12 percent in the small rural town areas (Table 8.3). The number of EMTs per 100,000 population was greater in the rural categories than the urban category. In 2006 there was 318 EMTs per 100,000 in the large rural town areas, 285 per 100,000 in the Figure 8.1. Emergency Medical Technician Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 8.2. Emergency Medical Technicians per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, Population estimates provided by U.S. Census Bureau. 8-1

84 Figure 8.3. Emergency Medical Technician Profile for Arizona s Four Rural Urban Commuting Areas: Figure 8.4. Emergency Medical Technicians per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, Population estimates provided by Claritas. small rural town areas, 383 per 100,000 in the isolated small rural town areas, and 237 per 100,000 in the urban areas. Table 8.4 shows the five year trends. 8.1 Summary There were 15,032 Arizona certified emergency medical technicians in From 2002 to 2006, the number of EMTs increased 25 percent (+3,049). The number of EMTs increased 27 percent in the urban classified counties, 21 percent in the rural-urban classified counties, and 21 percent in the rural-rural classified counties from 2002 to The state wide EMT-population ratios increased from 220 per 100,000 in 2002 to 244 per 100,000 in The greatest increase in numbers of EMTs occurred in the urban classified counties. In 2006, EMTpopulation ratios were larger in rural area than urban areas. 8.2 References 1. The New York Center for Health Workforce Studies (2006). The United States Workforce Profile, Health Resources and Services Administration, DHHS. pp

85 Table 8.1. Emergency Medical Technicians: Arizona County Changes between 2002 and 2006 County Number in 2002 Number in 2006 Net Change from Percent Change from 2002 to to 2006 Apache % Cochise % Coconino % Gila % Graham % Greenlee % La Paz % Maricopa 6,059 7,766 1,707 28% Mohave % Navajo % Pima 2,068 2, % Pinal % Santa Cruz % Yavapai % Yuma % Arizona Total 11,983 15,032 3,049 25% Urban Counties 8,127 10,359 2,232 27% Rural-Urban Counties 951 1, % Rural-Rural Counties 2,905 3, % Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, Table 8.2. Emergency Medical Technicians per 100,000 Population: Arizona County Changes between County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Arizona Total Urban Counties Rural-Urban Counties Rural-Rural Counties Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, Population estimates provided by the U.S. Census Bureau. 8-3

86 Table 8.3. Emergency Medical Technicians: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Number in 2002 Number in 2006 Net Change from Percent Change 2002 to 2006 from 2002 to 2006 Arizona - Total 11,983 15,032 3,049 25% Urban 9,465 12,195 2,730 29% Large Rural Towns 1,188 1, % Small Rural Towns 967 1, % Isolated Small Rural Towns % Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, Table 8.4. Emergency Medical Technicians per 100,000 Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA Arizona Total Urban Large Rural Towns Small Rural towns Isolated Small Rural Towns Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, Population estimates provided by Claritas. 8-4

87 SECTION 9: CONCLUSIONS AND RECOMMENDATIONS 9.1 Conclusions The spatial distribution of healthcare workforce inequalities between urban and rural areas from 2002 to 2006 continues to exist or have become worse for rural areas except for physician assistants and emergency medical technicians. The 17 health professions examined were compared based on the five-year period of and on numbers in From 2002 to 2006, Arizona s healthcare workforce coverage of licensed professionals slightly increased for most of the 17 professions with the numbers of pharmacy technicians and physician assistants per 100,000 population showing the largest increase. Then numbers of obstetricians and gynecologists per 100,000 slightly decreased. Arizona is one of the fastest growing states in the nation. It experienced a 13.2 percent increase in population from 2002 to The two urban counties, Maricopa and Pima, accounted for 76.5 percent of the state s population in These two counties experienced a population growth of 13.1 percent while the rural-rural classified counties had slightly larger growth rate of 14.9 percent during the five-year period. Pinal County had the largest population growth (36.0%), while Greenlee County decreased 3.1% in population. Based on rural urban commuting area (RUCA) classification system for ruralness, the urban areas population increased 11.8%, followed by large rural town areas (10.1%). The number of primary care professionals (primary care physicians, physician assistants, and nurse practitioners) has increased in the state, but there are still primary care physicians and nurse practitioners distribution inequalities between urban and rural areas. Arizona depends on other states and countries to produce the majority of primary care physicians that serves its population. Five rural-rural classified counties were ranked lowest in number of health professional per 100,000 population for the state in Apache and La Paz counties were ranked in bottom for 15 out of the 17 health professionals examined, Santa Cruz County was ranked in the bottom for 11 out of 17 health professionals, Pinal County was ranked in the bottom for 10 out of 17, and Greenlee County was ranked in the bottom for 9 out of 17. (Appendix E, Tables E.1 and E.2) 9.2 Recommendations Arizona needs to increase its financial support of state health professional programs to replace the large number of retiring professionals of the baby boomers generation and increase the numbers of rural health workers; especially, for the Apache, La Paz, Santa Cruz, Pinal and Greenlee counties. The Arizona health professional programs need to increase the number rural health practitioners in the state. To do this the state s health professional programs need to increase their recruitment efforts of students from rural areas, to expand rural health content in their academic curriculum, and to increase the number of practice rotation in rural health facilities. Arizona needs to expand its health professional loan payment program and J-1 Visa program that targets recruitment for rural areas. Assuring sufficient primary care physicians in rural Arizona will require targeted incentives in physician recruitment and an increase in medical residency programs in rural areas. Further workforce studies are needed to examine the effects of the Patient Protection and Affordable Care Act on rural health workforce, policies of the State of Arizona, the impact of health facility expansions (e.g., federal qualified community health centers and their satellites, rural health clinics, and hospitals) on rural health workforce, the effects of the aging of rural populations on the demand of health services, the impact of the aging health workforce on the delivery of rural healthcare, and effects of health technology on workforce needs. 9-1

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89 SECTION 10: APPENDICES Appendix A. List of Tables 1. Introduction Table and 2004 State Health Workforce Profile Publications: Arizona 1-2 Health Workforce Changes Table 1.2 Arizona Health Workforce Profile for Selected Professionals: Physicians Table 3.1 Total Physicians (MDs and DOs): Arizona County Changes between and 2006 Table 3.2 Total Physicians (MDs and DOs) per 100,000 Population: Arizona 3-13 County Changes between Table 3.3 Total Physicians (MDs and DOs): Arizona s Four Rural Urban 3-14 Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.4 Total Physicians (MDs and DOs) per 100,000 Population: Arizona s 3-14 Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.5 Total Allopathic Physicians (MDs): Arizona County Changes 3-14 between 2002 and 2006 Table 3.6 Total Allopathic Physicians (MDs) per 100,000 Population: 3-15 Arizona County Changes between Table 3.7 Total Allopathic Physicians (MDs): Arizona s Four Rural Urban 3-15 Commuting Areas (RUCA) Changes between 2002 and 2007 Table 3.8 Total Allopathic Physicians (MDs) per 100,000 Population: 3-15 Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Table 3.9 Total Osteopathic (DO) Physicians: Arizona County Changes 3-16 between 2002 and 2006 Table 3.10 Total Osteopathic Physicians (DOs) per 100,000 Population: 3-16 Arizona County Changes between 2002 and 2006 Table 3.11 Total Osteopathic Physicians (DOs): Arizona s Four Rural Urban 3-17 Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.12 Total Osteopathic Physicians (DOs) per 100,000 Population: 3-17 Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.13 Primary Care Physicians (MDs and DOs): Arizona County Changes 3-17 between 2002 and

90 Table 3.14 Primary Care Physicians (MDs and DOs) per 100,000 Population: 3-18 Arizona County Changes between 2002 and 2006 Table 3.15 Allopathic (MD) Primary Care Physicians: Arizona County Changes 3-18 between 2002 and 2006 Table 3.16 Osteopathic (DO) Primary Care Physicians: Arizona County Changes 3-19 between 2002 and 2006 Table 3.17 Primary Care Physicians (MDs and DOs): Arizona s Four Rural 3-19 Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.18 Primary Care Physicians (MDs and DOs) per 100,000 Population: 3-19 Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.19 Total Physician Specialists (MDs and DOs): Arizona County 3-20 Changes between 2002 and 2006 Table 3.20 Total Physician Specialists (MDs and DOs) per 100,000 Population: 3-20 Arizona County Changes between 2002 and 2006 Table 3.21 Allopathic (MD) Specialist Physicians: Arizona County Changes 3-21 between 2002 and 2006 Table 3.22 Osteopathic (DO) Specialist Physicians: Arizona County Changes 3-21 between 2002 and 2006 Table 3.23 Specialist Physicians (MDs and DOs): Arizona s Four Rural Urban 3-22 Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.24 Specialist Physicians (MDs and DOs) per 100,000 Population: 3-22 Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.25 Obstetrics/Gynecology Physicians (MDs and DOs): Arizona County 3-22 Changes Between 2002 and 2006 Table 3.26 Obstetrics/Gynecology Physicians (MDs and DOs) per 100, Women of Child Bearing Age (15 44 y/o): Arizona County Changes Between 2002 and 2006 Table 3.27 Allopathic (MD) Obstetrics/Gynecology Physicians: Arizona County 3-23 Changes between 2002 and Table 3.28 Osteopathic (DO) Obstetrics/Gynecology Physicians: Arizona County 3-24 Changes between 2002 and 2006 Table 3.29 Obstetrics/Gynecology Physicians (MDs and DOs): Arizona s Four 3-24 Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.30 Obstetrics/Gynecology Physicians (MDs and DOs) per 100,000 Women 3-24 of Child Bearing Age: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and

91 Table 3.31 Psychiatric Physicians (MD and DO): Arizona County Changes between and 2006 Table 3.32 Psychiatric Physicians (MD and DO): per 100,000 Population: 3-25 Arizona County Changes between 2002 and 2006 Table 3.33 Psychiatric Physicians (MD and DO): Arizona s Four Rural Urban 3-26 Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.34 Psychiatric Physicians (MD and DO) per 100,000 Population: 3-26 Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Table 3.35 Direct, Primary Care Physician Coverage per 100,000 Population in by Arizona County Classification of Ruralness Table 3.36 Direct, Primary Care Physician Coverage per 100,000 Population in by Zip Code based Arizona Rural Urban Commuting Areas Classification 4. Physician Assistants Table 4.1 Physicians Assistants: Arizona County Changes between 2002 and Table 4.2 Physician Assistants per 100,000 Population: Arizona County Changes 4-3 between Table 4.3 Physician Assistants: Arizona s Four Rural Urban Commuting Areas 4-4 (RUCA) Changes between 2002 and 2007 Table 4.4 Physician Assistants per 100,000 Population: Arizona s Four Rural 4-4 Urban Commuting Areas (RUCA) Changes between 2002 and Nurses Table 5.1 Registered Nurses (RNs): Arizona County Changes between and 2007 Table 5.2 Registered Nurses (RNs) per 100,000 Population: Arizona County 5-9 Changes between 2002 and 2007 Table 5.3 Registered Nurses (RNs): Arizona s Four Rural Urban Commuting 5-10 Areas (RUCA) Changes between 2002 and 2007 Table 5.4 Registered Nurses (RNs) per 100,000 Population: Arizona s Four 5-10 Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.5 Certified Registered Nurse Anesthetist (CRNAs): Arizona County Changes between 2002 and Table 5.6 Certified Registered Nurse Anesthetist (CRNAs) per 100, Population: Arizona County Changes between 2002 and

92 Table 5.7 Certified Registered Nurse Anesthetist (CRNAs): Arizona s Four 5-11 Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.8 Certified Registered Nurse Anesthetist (CRNAs) per 100, Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.9 Nurse Practitioners (NPs): Arizona County Changes between and 2007 Table 5.10 Nurse Practitioners (NPs) per 100,000 Population: Arizona County 5-12 Changes between 2002 and 2007 Table 5.11 Nurse Practitioners (NPs): Arizona s Four Rural Urban Commuting 5-13 Areas (RUCA) Changes between 2002 and 2007 Table 5.12 Nurse Practitioners (NPs) per 100,000 Population: Arizona s Four 5-13 Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.13 Certified Nurse Midwives (CNMs): Arizona County Changes 5-13 Between 2002 and 2007 Table 5.14 Certified Nurse Midwives (CNMs) per 100,000 Women of Child 5-14 Bearing Age (15 44 y/o): Arizona County Changes Between 2002 and 2007 Table 5.15 Certified Nurse Midwives (CNMs): Arizona s Four Rural Urban 5-14 Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.16 Certified Nurse Midwives (CNMs) per 100,000 Women of Child 5-14 Bearing Age: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.17 Licensed Practical Nurses (LPNs): Arizona County Changes between and 2007 Table 5.18 Licensed Practical Nurses (LPNs) per 100,000 Population: Arizona 5-15 County Changes between 2002 and 2007 Table 5.19 Licensed Practical Nurses (LPNs): Arizona s Four Rural Urban 5-16 Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.20 Licensed Practical Nurses (LPNs) per 100,000 Population: Arizona s 5-16 Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.21 Certified Nurse Assistants (CNAs): Arizona County Changes Between and 2007 Table 5.22 Certified Nurse Assistants (CNAs) per 100,000 Population: Arizona 5-17 County Changes Between 2002 and

93 Table 5.23 Certified Nurse Assistants (CNAs): Arizona s Four Rural Urban 5-17 Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.24 Certified Nurse Assistants (CNAs) per 100,000: Arizona s Four Rural 5-17 Urban Commuting Areas (RUCA) Changes between 2002 and Dentists Table 6.1 Number of Office Locations per Dentist in Arizona: Table 6.2 Total Dentists: Arizona County Changes between 2002 and Table 6.3 Total Dentists per 100,000 Population: Arizona County Changes 6-7 between Table 6.4 Total Dentists: Arizona s Four Rural Urban Commuting Areas 6-7 (RUCA) Changes between 2002 and 2006 Table 6.5 Total Dentists per 100,000 Population: Arizona s Four Rural Urban 6-7 Commuting Areas (RUCA) Changes between 2002 and 2006 Table 6.6 General Dentists: Arizona County Changes between 2002 and Table 6.7 General Dentists per 100,000 Population: Arizona County Changes 6-8 between Table 6.8 General Dentists: Arizona s Four Rural Urban Commuting Areas 6-9 (RUCA) Changes between 2002 and 2007 Table 6.9 General Dentists per 100,000 Population: Arizona s Four Rural Urban 6-9 Commuting Areas (RUCA) Changes between 2002 and 2006 Table 6.10 Dentist Specialists: Arizona County Changes between 2002 and Table 6.11 Dentist Specialists per 100,000 Population: Arizona County Changes 6-10 between 2002 and 2006 Table 6.12 Dentist Specialists: Arizona s Four Rural Urban Commuting Areas 6-10 (RUCA) Changes between 2002 and 2006 Table 6.13 Dentist Specialists per 100,000 Population: Arizona s Four Rural 6-10 Urban Commuting Areas (RUCA) Changes between 2002 and Pharmacists and Pharmacy Technicians Table 7.1 Pharmacists: Arizona County Changes between 2002 and Table 7.2 Pharmacists per 100,000 Population: Arizona County Changes 7-5 between Table 7.3 Pharmacists: Arizona s Four Rural Urban Commuting Areas 7-6 (RUCA) Changes between 2002 and 2006 Table 7.4 Pharmacists per 100,000 Population: Arizona s Four Rural Urban 7-6 Commuting Areas (RUCA) Changes between 2002 and

94 Table 7.5 Pharmacy Technicians: Arizona County Changes between and 2007 Table 7.6 Pharmacy Technicians per 100,000 Population: Arizona County 7-7 Changes between Table 7.7 Pharmacy Technicians: Arizona s Four Rural Urban Commuting 7-7 Areas (RUCA) Changes between 2004 and 2007 Table 7.8 Pharmacy Technicians per 100,000 Population: Arizona s Four 7-7 Rural Urban Commuting Areas (RUCA) Changes between 2004 and Emergency Medical Technicians Table 8.1 Emergency Medical Technicians: Arizona County Changes 8-3 between 2002 and 2006 Table 8.2 Emergency Medical Technicians per 100,000 Population: 8-3 Arizona County Changes between Table 8.3 Emergency Medical Technicians: Arizona s Four Rural Urban 8-4 Commuting Areas (RUCA) Changes between 2002 and 2006 Table 8.4 Emergency Medical Technicians per 100,000 Population: 8-4 Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 Appendix D: Data Sources and Methods Table D.1 List of Town and Cities in Arizona and their Ruralness Classifications Table D.2 Estimated Cover per 100,000 population of Healthcare Workforce in 2004 for Arizona and United States Appendix E: Arizona, Counties, and RUCAs Health Workforce Comparisons Table E.1 Arizona, Counties, and RUCAs Health Professional Percentage Changes: Table E.2 Arizona, Counties, and RUCAs Health Professional.Population Ratios:

95 Appendix B. List of Figures 2. Arizona Characteristics Figure 2.1 Age Group Distribution for U.S. and Arizona: Figure 2.2 Age Group Distribution for Arizona: 2000 and Figure 2.3 Race/Ethnicity Distribution for U.S. and Arizona: Percent of Population Figure 2.4 Race/Ethnicity Distribution for Arizona: 2000 and Percent of Population 3. Physicians Figure 3.1 Total Physician (MD and DO) Profile for Arizona and 3-1 Urban/Rural-Urban/Rural-Rural Counties: Figure 3.2 Total Physicians (MDs and DOs) per 100,000 Population Profile for 3-1 Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.3 Total Physician (MD and DO) Profile for Arizona s Four 3-2 Rural Urban Commuting Areas: Figure 3.4 Total Physicians (MDs and DOs) per 100,000 Population Profile for 3-2 Arizona s Four Rural Urban Commuting Areas: Figure 3.5 Total Allopathic Physician (MD) Profile for Arizona and 3-3 Urban/Rural-Urban/Rural-Rural Counties: Figure 3.6 Total Allopathic Physicians (MDs) per 100,000 Population Profile for 3-3 Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.7 Total Allopathic Physician (MD) Profile for Arizona s Four Rural 3-3 Urban Commuting Areas: Figure 3.8 Total Allopathic Physicians (MDs) per 100,000 Population Profile for 3-3 Arizona s Four Rural Urban Commuting Areas: Figure 3.9 Total Osteopathic Physician (DO) Profile for Arizona and 3-4 Urban/Rural-Urban/Rural-Rural Counties: Figure 3.10 Total Osteopathic Physicians (DOs) per 100,000 Population Profile for 3-4 Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.11 Total Osteopathic Physician (DO) Profile for Arizona s Four 3-4 Rural Urban Commuting Areas: Figure 3.12 Total Osteopathic Physicians (DOs) per 100,000 Population Profile 3-4 for Arizona s Four Rural Urban Commuting Areas: Figure 3.13 Total Primary Care Physician (MD and DO) Profile for Arizona and 3-5 and Urban/Rural-Urban/Rural-Rural Counties:

96 Figure 3.14 Total Primary Care Physicians (MDs and DOs) per 100,000 Population 3-5 Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.15 Allopathic Primary Care Physician (MD) Profile for Arizona 3-5 and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.16 Osteopathic Primary Care Physician (DO) Profile for Arizona 3-5 and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.17 Total Primary Care Physician (MD and DO) Profile for Arizona s 3-6 Four Rural Urban Commuting Areas: Figure 3.18 Total Primary Care Physicians (MDs and DOs) per 100, Population Profile for Arizona s Four Rural Urban Commuting Areas: Figure 3.19 Total Specialist Physician (MD and DO) Profile for Arizona and 3-7 Urban/Rural-Urban/Rural-Rural Counties: Figure 3.20 Total Specialist Physicians (MDs and DOs) per 100,000 Population 3-7 Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.21 Allopathic Specialist Physician (MD) Profile for Arizona and 3-8 Urban/Rural-Urban/Rural-Rural Counties: Figure 3.22 Osteopathic Specialist Physician (DO) Profile for Arizona and 3-8 Urban/Rural-Urban/Rural-Rural Counties: Figure 3.23 Total Specialist Physician (MD and DO) Profile for Arizona s 3-8 Four Rural Urban Commuting Areas: Figure 3.24 Total Specialist Physicians (MDs and DOs) per 100, Population Profile for Arizona s Four Rural Urban Commuting Areas: Figure 3.25 Total Obstetrics/Gynecology Physician (MD and DO) Profile 3-9 for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.26 Total Obstetrics/Gynecology Physicians (MDs and DOs) per 100, Women of Child Bearing (15-44 Year Old) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.27 Allopathic (MD) Obstetrics/Gynecology Physician Profile for 3-9 Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.28 Osteopathic (DO) Obstetrics/Gynecology Physician Profile for 3-9 Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.29 Total Obstetrics/Gynecology Physician (MD and DO) Profile 3-10 for Arizona s Four Rural Urban Commuting Areas:

97 Figure 3.30 Total Obstetrics/Gynecology Physicians (MDs and DOs) per ,000 Women of Child Bearing (15-44 Year Old) Profile for Arizona Four Rural Urban Commuting Areas: Figure 3.31 Psychiatric Physician (MD and DO) Profile for Arizona and 3-10 Urban/Rural-Urban/Rural-Rural Counties: Figure 3.32 Psychiatric Physicians (MDs and DOs) per 100,000 Population 3-10 Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 3.33 Psychiatric Physician (MD and DO) Profile for Arizona s 3-11 Four Rural Urban Commuting Areas: Figure 3.34 Psychiatric Physicians (MDs and DOs) per 100,000 Population 3-11 Profile for Arizona Four Rural Urban Commuting Areas: Physician Assistants Figure 4.1 Physician Assistant Profile for Arizona and Urban/ 4-1 Rural-Urban/Rural-Rural Counties: Figure 4.2 Physician Assistants per 100,000 Population Profile for Arizona 4-1 and Urban/Rural-Urban/Rural-Rural Counties: Figure 4.3 Physician Assistant Profile for Arizona s Four Rural 4-2 Urban Commuting Areas: Figure 4.4 Physician Assistants per 100,000 Population Profile for 4-2 Arizona s Four Rural Urban Commuting Areas: Nurses Figure 5.1 Registered Nurse (RN) Profile for Arizona and 5-1 Urban/Rural-Urban/Rural-Rural Counties: Figure 5.2 Registered Nurses (RNs) per 100,000 Population Profile for 5-1 Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 5.3 Registered Nurse (RN) Profile for Arizona s Four Rural 5-2 Urban Commuting Areas: Figure 5.4 Registered Nurses (RNs) per 100,000 Population Profile for 5-2 Arizona s Four Rural Urban Commuting Areas: Figure 5.5 Certified Registered Nurse Anesthetist (CRNA) Profile for Arizona 5-2 and Urban/Rural-Urban/Rural-Rural Counties: Figure 5.6 Certified Registered Nurse Anesthetists (CRNAs) per 100, Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties:

98 Figure 5.7 Certified Registered Nurse Anesthetist (CRNA) Profile for 5-3 Arizona s Four Rural Urban Commuting Areas: Figure 5.8 Certified Registered Nurse Anesthetists (CRNAs) per 100, Population Profile for Arizona s Four Rural Urban Commuting Areas: Figure 5.9 Nurse Practitioner (NP) Profile for Arizona and 5-3 Urban/Rural-Urban/Rural-Rural Counties: Figure 5.10 Nurse Practitioners (NPs) per 100,000 Population Profile for 5-3 Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 5.11 Nurse Practitioner (NP) Profile for Arizona s Four Rural 5-4 Urban Commuting Areas: Figure 5.12 Nurse Practitioners (NPs) per 100,000 Population Profile for 5-4 Arizona s Four Rural Urban Commuting Areas: Figure 5.13 Certified Nurse Midwife (CNM) Profile for Arizona and 5-5 Urban/Rural-Urban/Rural-Rural Counties: Figure 5.14 Certified Nurse Midwives (CNMs) per 100,000 Women of Child 5-5 Bearing (15-44 Year Old) Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: Figure 5.15 Certified Nurse Midwife (CNM) Profile for Arizona s 5-5 Four Rural Urban Commuting Areas: Figure 5.16 Certified Nurse Midwives (CNMs) per 100,000 Women of Child 5-5 Bearing (15-44 Year Old) Profile for Arizona s Four Rural Urban Commuting Areas: Figure 5.17 Licensed Practical Nurse (LPN) Profile for Arizona and 5-6 Urban/Rural-Urban/Rural-Rural Counties: Figure 5.18 Licensed Practical Nurses (LPNs) per 100,000 Population Profile for 5-6 Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 5.19 Licensed Practical Nurse (LPN) Profile for Arizona s Four Rural 5-6 Urban Commuting Areas: Figure 5.20 Licensed Practical Nurses (LPNs) per 100,000 Population Profile for 5-6 Arizona s Four Rural Urban Commuting Areas: Figure 5.21 Certified Nurse Assistant (CNA) Profile for Arizona and 5-7 Urban/Rural-Urban/Rural-Rural Counties: Figure 5.22 Certified Nurse Assistants (CNAs) per 100,000 Population Profile 5-7 for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 5.23 Certified Nurse Assistant (CNA) Profile for Arizona s Four Rural 5-7 Urban Commuting Areas:

99 Figure 5.24 Certified Nurse Assistants (CNAs) per 100,000 Population Profile for 5-7 Arizona s Four Rural Urban Commuting Areas: Dentists Figure 6.1 Total Dentist Profile for Arizona and Urban/Rural-Urban/ 6-1 Rural-Rural Counties: Figure 6.2 Total Dentists per 100,000 Population Profile for Arizona and 6-1 Urban/Rural-Urban/Rural-Rural Counties: Figure 6.3 Total Dentist Profile for Arizona s Four Rural Urban Commuting 6-2 Areas: Figure 6.4 Total Dentists per 100,000 Population Profile for Arizona s 6-2 Four Rural Urban Commuting Areas: Figure 6.5 General Dentist Profile for Arizona and Urban/Rural-Urban/ 6-2 Rural-Rural Counties: Figure 6.6 General Dentists per 100,000 Population Profile for Arizona and 6-2 Urban/Rural-Urban/Rural-Rural Counties: Figure 6.7 General Dentist Profile for Arizona s Four Rural Urban 6-3 Commuting Areas: Figure 6.8 General Dentists per 100,000 Population Profile for Arizona s 6-3 Four Rural Urban Commuting Areas: Figure 6.9 Specialist Dentist Profile for Arizona and Urban/Rural-Urban/ 6-3 Rural-Rural Counties: Figure 6.10 Specialist Dentists per 100,000 Population Profile for Arizona 6-3 and Urban/Rural-Urban/Rural-Rural Counties: Figure 6.11 Specialist Dentist Profile for Arizona s Four Rural Urban 6-4 Commuting Areas: Figure 6.12 Specialist Dentists per 100,000 Population Profile for Arizona s 6-4 Four Rural Urban Commuting Areas: Pharmacists and Pharmacy Technicians Figure 7.1 Pharmacist Profile for Arizona and Urban/Rural-Urban/ 7-1 Rural-Rural Counties: Figure 7.2 Pharmacists per 100,000 Population Profile for Arizona and 7-1 Urban/Rural-Urban/Rural-Rural Counties: Figure 7.3 Pharmacist Profile for Arizona s Four Rural Urban Commuting 7-2 Areas: Figure 7.4 Pharmacists per 100,000 Population Profile for Arizona s Four 7-2 Rural Urban Commuting Areas:

100 Figure 7.5 Pharmacy Technician Profile for Arizona and Urban/Rural- 7-3 Urban/Rural-Rural Counties: Figure 7.6 Pharmacy Technicians per 100,000 Population Profile for 7-3 Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 7.7 Pharmacy Technician Profile for Arizona s Four Rural Urban 7-3 Commuting Areas: Figure 7.8 Pharmacy Technicians per 100,000 Population Profile for 7-3 Arizona s Four Rural Urban Commuting Areas: Emergency Medical Technicians Figure 8.1 Emergency Medical Technician Profile for Arizona and 8-1 Urban/Rural-Urban/Rural-Rural Counties: Figure 8.2 Emergency Medical Technicians per 100,000 Population 8-1 Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: Figure 8.3 Emergency Medical Technician Profile for Arizona s 8-2 Four Rural Urban Commuting Areas: Figure 8.4 Emergency Medical Technicians per 100,000 Population 8-2 Profile for Arizona Four Rural Urban Commuting Areas:

101 Appendix C. List of Maps 2. Arizona Characteristics Map 2.1 Map of Arizona counties based on surface-area and 2-1 a cartogram based on population Map 2.2 Populations of Cities and Towns by Arizona Counties and 2-2 Land Ownership Map 2.3 Arizona s Urban, Rural-Urban, and Rural-Rural Counties 2-4 Map 2.4 Populations of Cities and Towns by RUCA Zip Code Geography 2-4 Map 2.5 Arizona s American Indian Tribes Physicians Map 3.1 Physicians/Population Ratios by Arizona Counties for Map 3.2 Allopathic Physicians/Population Ratios by Arizona Counties for Map 3.3 Osteopathic Physicians/Population Ratios by Arizona Counties for Map 3.4 Primary Care Physicians/Population Ratios by Arizona Counties for Map 3.5 Arizona Primary Care Health Professional Shortage Areas: 3-6 February 2010 Map 3.6 Specialist Physicians/Population Ratios by Arizona Counties for Map 3.7 Obstetrics/Gynecology Physicians/Women of Child Bearing Age Ratios 3-8 by Arizona Counties for 2006 Map 3.8 Psychiatric Physicians/Population Ratios by Arizona Counties for Physician Assistants Map 4.1 Physician Assistants/Population Ratios by Arizona Counties for Nurses Map 5.1 Registered Nurses/Population Ratios by Arizona Counties for Map 5.2 Certified Registered Nurse Anesthetist/Population Ratios 5-3 by Arizona Counties for 2007 Map 5.3 Certified Nurse Practitioners/Population Ratios by Arizona Counties for Map 5.4 Certified Nurse Midwives/Women of Child Bearing Age Ratios by 5-5 Arizona Counties for 2007 Map 5.5 Licensed Practical Nurses/Population Ratios by Arizona Counties for

102 Map 5.6 Certified Nurse Assistants/Population Ratios by Arizona Counties for Dentists Map 6.1 Dentists/Population Ratios by Arizona Counties for Map 6.2 General Dentists/Population Ratios by Arizona Counties for Map 6.3 Specialist Dentists/Population Ratios by Arizona Counties for Map 6.4 Arizona Dental HPSA Designation: April Pharmacists and Pharmacy Technicians Map 7.1 Pharmacists/Population Ratios by Arizona Counties for Map 7.2 Pharmacy Technicians/Population Ratios by Arizona Counties for Emergency Medical Technicians Map 8.1 Emergency Medical Technicians/Population Ratios by Arizona 8-1 Counties for 2006 Appendix D: Data Sources and Methods Map D.1 Arizona Counties Based on Surface-Area and Population Map D.2 Ruralness Base on County Classifications in Arizona Map D.3 Ruralness by Rural Urban Commuting Areas that Are Based on Zip Code Geography in Arizona 10-14

103 Appendix D. Data Sources and Methods D.1 Data Sources Data sources used in this report are as follow: Arizona Department of Health Services (ADHS) datasets from 2000 to 2006 that comprised board data on allopathic (MD) and osteopathic (DO) physicians, physician assistants, nurse practitioners, midwives, registered nurses, dentists, and emergency medical technicians. The origin of this data was from the following licensing boards: Arizona Medical Board; Arizona State Board of Nursing; Arizona State Board of Dental Examiners; and ADHS s Emergency Medical Technicians certification data. Any modifications of the data by ADHS were undocumented. Arizona Medical Board data of past and current allopathic physicians as of February American Medical Association s physician dataset for November 2008 provided medical school and residency locations. Arizona State Board of Nursing data on current and past nurses (advanced practice registered nurses, registered nurses, licensed practical nurses, and certified nursing assistants) as of October Arizona State Board of Dental Examiners of current dentists as of September Arizona State Board of Pharmacy of past and current pharmacists and pharmacist technicians as of May The US Census for county-level populations and inter-census, annual population estimates. Nielsen Claritas, a marketing research company, for zipcode-level population estimates. These estimates do not necessarily match the US Census estimates exactly at the state-level. University of Washington s Rural Urban Commuting Area (RUCA) classifications by zipcodes ( D.2 Methods Accurate health care workforce analysis for rural areas requires higher quality data than urban areas (Figure D.1) because of the small numbers of professionals working in the rural communities and the small populations in these communities. Random or systematic data errors can severely distort the results and resulting recommendations. Aggregating the data by different geographies with small population densities can help identify needs for different communities and underserved populations. Map D.1. Map of Arizona counties based on surface-area and a cartogram based on population

104 The summary data was reported for each of Arizona s 15 counties and by three County Ruralness classifications. County Ruralness is an ad hoc classification that was used in the previous Arizona Rural Health Plan where those practitioners located in Maricopa or Pima counties were classified as urban, practitioners located in Coconino and Yuma counties were classified as rural-urban, and the remaining counties were classified as rural-rural (Figure D.2). The county based classification defined the two urban counties based on having at least one community with a population of 500,000 or greater. Although these two counties are classified as urban, they also include large rural areas (e.g., the Tohono O odham Reservation in Pima County). State rural areas have been subdivided into two categories: rural-urban which includes counties that have a community with a population of 50,000 or greater (technically urban according to the U.S. Census Bureau while the rest of the county is rural), and rural-rural which includes counties in which all communities have a population of less than 50,000. The summary data was also reported by rural-urban commuting areas (RUCA) that used postal zip code geography to compare differences in the levels of community rurality in the state. RUCAs are based on US Census tract data and provide a standard, nationwide classification of ruralness. RUCA s were converted to zip code geographies by the University of Washington ( edu/uwruca/). The four categories of RUCAs that were used are: urban areas (e.g., Phoenix), large rural town areas (e.g., Payson), small rural town areas (e.g., Chinle), and isolated small rural town areas (e.g., Ashfork and Tombstone) (Figure D.3 and Table D.1). This four-category classification is commonly used for health related projects. It divides urban and rural areas approximately the same way as the US Office of Management and Budget s metro classification. Population estimates by zip codes were provided by Nielsen-Claritas, a marketing research company. Missing county and postal zip code data for residence or business locations of professionals were deductively imputed based on street address and/ or city data, and practitioners name and the use of a geographic information system and internet website search applications. Unclear determinations were assigned to the more urban locations to minimize relative error. Workforce summaries are presented as total counts and relative counts of currently licensed or certified Map D.2. Ruralness Based on County Classifications in Arizona Map D.3. Ruralness by Rural-Urban Commuting Areas that are Based on Zip Code Geography in Arizona professionals. These values likely over estimate the number of practicing, full-time equivalent (FTE), direct patient care professionals. The relative counts of professionals are presented as number of professionals per 100,000 population. The reference populations used were the populations likely served; specifically, the general population or the population of females of child bearing age from15 to 44 years. Since US Census and Nielsen Claritas population estimates are not necessarily the same, the relative counts of practitioners at the state-level are likely to be slightly different between County Ruralness and RUCA estimates. The algorithms used for practicetype classifications are available upon request. Health professional licensing boards are the source of data most commonly used in healthcare workforce analysis. Much of these data were based on self