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

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

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.

TABLE OF CONTENTS Executive Summary 1. Introduction 1-1 Arizona Health Care Workforce Comparisons 1-1 Arizona Health Workforce Profiles 1-3 2. 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 2-4 3. 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 3-11 4. Physician Assistants 4-1 Summary 4-2 5. 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

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 6-4 7. Pharmacists and Pharmacy Technicians 7-1 Pharmacists 7-1 Pharmacy Technicians 7-2 Pharmacists and Pharmacy Technician Practice Profiles 7-3 Summary 7-3 8. Emergency Medical Technicians 8-1 Summary 8-2 9. Conclusions and Recommendations 9-1 10. Appendices 10-1 A. List of Tables 10-1 B. List of Figures 10-7 C. List of Maps 10-13 D. Data Sources and Methods 10-15 E. Arizona, Counties, and RUCAs Health Workforce Comparisons 10-25

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 2006. 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.

LEFT BLANK

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

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 2000 172.0 198.0 33/50 2004 191.0 214.1 35/50 Physician Assistants 1999 2004 Nurse Practitioners 1998 2004 Certified Nurse Midwives 2000 2004 Registered Nurses 1996 2004 Licensed Practical Nurses 2000 2004 Dentists 2000 2004 Pharmacists 1998 2004 Psychologists 1998 2004 Source: National Center for Health Force Analysis 11.0 17.6 25.1 45.7 2.7 5.5 735.4 678.0 168.2 141.0 44.0 51.8 47.1 66.7 26.1 32.9 10.4 16.9 26.3 42.0 2.1 15.0 797.7 802.0 240.8 239.3 63.6 59.4 65.9 77.0 31.2 33.5 27/50 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 2004-2006, 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. 1-97. 2. The New York Center for Health Workforce Studies. (2006) The United States Health Workforce Profile. pp. 1-159. 1-2

Table 1.2. Arizona Health Workforce Profile for Selected Professionals: 2006 Health Profession Number in Net Chg from Percent Chg Number Number Chg 2006 2002 to 2006 (2002 to 2006) /100,000 (2002 to 2006) Physicians 13,429 1,826 16% 218 +5/100,000 Primary Care Physicians 4,424 680 18% 72 +3/100,000 Specialist Physicians 9,005 1,146 15% 146 +2/100,000 OB/GYN Physicians 752 51 7% 60* -2/100,000 Psychiatrist Physicians 665 43 7% 11 No Change Physician Assistants 1,336 442 46% 22 +5/100,000 Registered Nurses 51,122 6,616 15% 829 +12/100,000 Nurse Practitioners 2,113 601 40% 34 +6/100,000 Certified Nurse Midwives 154 14 10% 12** No Change Licensed Practical Nurses 8,754 1,751 25% 142 +13/100,000 Certified Nurse Assistants 20,360 2,038 11% 330-6/100,000 Dentists 3,316 730 28% 54 +7/100,000 General Dentists 2,693 529 24% 44 +4/100,000 Specialist Dentists 623 201 48% 10 +2/100,000 Pharmacists 4,965 1,347 37% 81 +15/100,000 Pharmacy Technicians 6,096 2,721 @ 81% @ 99 +40/100,000 Emergency Med. Tech. 15,032 3,049 25% 244 +24/100,000 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 y/o). @ Change for only 2004 to 2006; pharmacy technicians were not certified by the State Board of Pharmacy before 2004. Population estimates provided by US-Census. @ 1-3

LEFT BLANK

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 45-54 and 55-64 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. http://www.raconline.org/info_guides/frontier/ b. With the inclusion of sacred areas of Zuni tribal land there are 22 federally recognized American Indian tribal lands in Arizona. 2-1

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

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 2005-2007, 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, 2011. 2-3

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

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 http://www.epa.gov/ Border2012/docs/LaPazAgreement.pdf 2-5

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. 1-152. 2. 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. 1-55., Appendices A-I. 3. A.R.S. 36-2171. (2004). http://www.azleg.state. 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. 1-20. 5. Goldsmith, H.F., Puskin D.S., and Stiles D.J. (1993). Improving the Operational Definition of Rural Access for Federal Programs. pp. 1-11. 6. 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: http:// www.csrha.org/ 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 2005-2007, pp. 1-96. e. 638 refers to an agreement which states that tribes can operate a facility under a P.L. 93-638 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

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 2006. 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 191.0 physicians per 100,000 population, while the U.S. had an average of 214.1 per 100,000. 2 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 2006. 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: 2002-2006 Figure 3.2. Total Physicians (MD and DO) per 100,000 Population Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: 2002-2006 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, 2002-2006. 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. 3-1

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 2006. During the five year period (2002-2006), 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 2002-2006. 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 2002-2007 trends are presented in Table 3.8. Total Osteopathic Physicians: There were 1,493 active licensed osteopathic physicians (DO) in Arizona in 2006. During the five year period (2002 to Figure 3.3. Total Physicians (MD and DO) Profile for Arizona s Four Rural Urban Communting Areas: 2002-2006 Figure 3.4. Total Physicians (MD and DO) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas:2002-2006 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, 2002-2006. 3-2 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, 2002-2006. Population estimates provided by Claritas.

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: 2002-2007 Figure 3.6. Total Allopathic Physicians (MD) per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: 2002-2007 Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. Figure 3.7. Total Allopathic Physician (MD) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. 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: 2002-2007 Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. Population estimates provided by Claritas. 3-3

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 2006. 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: 2002-2006 Figure 3.10. Total Osteopathic Physicians (DO) per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: 2002-2006 Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Figure 3.11. Total Osteopathic Physician (DO) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Population estimates provided by the U.S. Census Bureau. Figure 3.12. Total Osteopathic Physicians (DO) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. 3-4 Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Population estimates provided by Claritas.

during 2002-2006. 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 100,000. 2 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 2006. The inequalities of primary care physician-population ratios between the urban and rural counties remained the same between 2002 and 2006. 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 3.13. Total Primary Care Physician (MD and DO) Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: 2002-2006 Figure 3.14. Total Primary Care Physicians (MD and DO) per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 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, 2002-2006. Figure 3.15. Allopathic Primary Care Physicians (MD) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. Figure 3.16. Osteopathic Primary Care Physician (DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. 3-5

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 3.18. 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 2010. Source: ADHS Figure 3.17. Total Primary Care Physician (MD and DO) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 3.18. Total Primary Care Phyysicians (MD and DO) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 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, 2002-2006. 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, 2002-2006. Population estimates provided by Claritas. 3-6

Arizona in 2006. 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 2006. 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 2002-2006 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 3.24. Figure 3.19. Total Specialist Physician (MD and DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.20. Total Specialist Physicians (MD and DO) per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 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, 2002-2006. 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. 3-7

Figure 3.21. Allopathic Specialist Physician (MD) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 3.22. Osteopathic Specialist Physician (DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Figure 3.23. Total Specialist Physician (MD and DO) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 3.24. Osteopathic Specialist Physician (MD) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 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, 2002-2006. 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, 2002-2006. 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 2006. 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 2006. There were no changes in the number of OB/GYNs in Apache (5), Cochise (10), Santa Cruz (4), and 3-8

Figure 3.25. Total Obstetrics/Gynecology Physician (MD and DO) Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: 2002-2006 Figure 3.26. 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: 2002-2006 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, 2002-2006. 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. Figure 3.27. Allopathic (MD) Obstetrics/Gynecology Physician Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: 2002-2007 Figure 3.28. Osteopathic (DO) Obstetrics/Gynecology Physician Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: 2002-2006 Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008. Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. 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 3.28. The 2002 to 2006 trends of OB/GYNs in the four RUCA categories are shown in Figures 3.29 and 3.30. 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 3.30. Psychiatric Physicians: There were 712 active licensed psychiatric physicians in Arizona in 2006. 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

Figure 3.29. Total Obstetrics/Gynecology Physician (MD and DO) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 3.30. 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: 2002-2006 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, 2002-2006. Figure 3.31. Psychiatric Physician (MD and DO) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 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, 2002-2006. Population estimates provided by Claritas. Figure 3.32. Psychiatric Physicians (MD and DO) per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: 2002-2006 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, 2002-2006. 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, 2002-2006. 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

Figure 3.33. Psychiatric Physician (MD and DO) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 3.34. Psychiatric Physicians (MD and DO) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 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, 2002-2006. 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, 2002-2006. 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 3.34. 3.2 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. 5 3.4 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 2006. 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 2006. The largest number of physicians per 100,000 population occurred in counties large population centers, Pima, Coconino, and Maricopa counties. The 3-11

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 2006. 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. 1-152. 2. The New York Center for Health Workforce Studies (2006). The United States Workforce Profile, Health Resources and Services Administration, DHHS. pp. 1-159. 3. 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: http://bhpr.hrsa.gov/shortage/primarycare.htm. 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 1992-2004. Center for Health Information and Research, Arizona State University, Tempe. pp. 1-62. 5. Rimsza, M.E., Johnson, W.G., Speicher M., and Grossman M. (2005). The Arizona Physician Workforce Study Part 2: The Number of Practicing Physicians 1992-2004. Center for Health Information and Research, Arizona State University, Tempe. pp. 1-55. 3-12

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 45 34-11 -24% Cochise 145 147 2 1% Coconino 276 296 20 7% Gila 72 75 3 4% Graham 29 33 4 14% Greenlee 7 8 1 14% La Paz 17 18 1 6% Maricopa 7,427 8,794 1,367 18% Mohave 232 297 65 28% Navajo 110 119 9 8% Pima 2,540 2,741 201 8% Pinal 150 197 47 31% Santa Cruz 33 34 1 3% Yavapai 320 385 65 20% Yuma 200 251 51 26% Arizona - Total 11,603 13,429 1,826 16% Urban Counties 9,967 11,535 1,568 16% Rural-Urban Counties 476 547 71 15% Rural-Rural Counties 1,160 1,347 187 16% 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, 2002-2006. Table 3.2. Total Physicians (MDs and DOs) per 100,000 Population: Arizona County Changes between 2002-2006 County 2002 2003 2004 2005 2006 Apache 67 66 51 54 49 Cochise 121 125 123 120 116 Coconino 229 243 243 248 235 Gila 141 142 155 151 146 Graham 88 79 89 98 99 Greenlee 91 81 68 68 107 La Paz 88 82 97 90 90 Maricopa 225 231 235 237 233 Mohave 140 148 149 152 155 Navajo 109 112 109 111 109 Pima 289 298 298 304 289 Pinal 76 82 87 82 73 Santa Cruz 84 88 77 83 81 Yavapai 179 192 199 199 186 Yuma 120 126 131 135 135 Arizona Total 213 220 222 225 218 Urban Counties 239 245 248 251 244 Rural-Urban Counties 166 174 178 181 175 Rural-Rural Counties 118 124 126 125 120 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. 3-13

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 556 634 78 14% Small Rural Town 374 406 32 9% Isolated Small Rural Town 61 61 0 0% 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, 2002-2006. 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 2002 2003 2004 2005 2006 Arizona Total 213 219 222 227 222 Urban 231 237 240 245 240 Large Rural Town 144 152 153 151 150 Small Rural Town 104 107 108 111 107 Isolated Small Rural Town 61 68 65 64 58 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, 2002-2006. 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 39 29-10 -26% Cochise 118 121 3 3% Coconino 260 272 12 5% Gila 66 60-6 -9% Graham 27 26-1 -4% Greenlee 6 8 2 33% La Paz 13 12-1 -8% Maricopa 6,645 7,748 1,103 17% Mohave 190 235 45 24% Navajo 91 95 4 4% Pima 2,370 2,554 184 8% Pinal 128 174 46 36% Santa Cruz 31 32 1 3% Yavapai 284 338 54 19% Yuma 183 232 49 27% Arizona Total 10,451 11,936 1,485 14% Urban Counties 9,015 10,302 1,287 14% Rural-Urban Counties 443 504 61 14% Rural-Rural Counties 993 1,130 137 14% Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. 3-14

Table 3.6. Total Allopathic Physicians (MDs) per 100,000 Population: Arizona County Changes between 2002-2007 County 2002 2003 2004 2005 2006 2007 Apache 58 59 43 45 42 39 Cochise 98 101 100 98 95 95 Coconino 216 229 230 233 216 222 Gila 129 130 132 132 117 119 Graham 82 73 80 88 78 60 Greenlee 78 68 68 68 107 103 La Paz 67 62 71 65 60 55 Maricopa 201 206 209 210 205 203 Mohave 115 123 118 119 123 124 Navajo 90 91 87 89 87 88 Pima 270 278 278 284 269 263 Pinal 65 71 75 71 65 56 Santa Cruz 79 78 70 75 76 82 Yavapai 159 169 172 173 163 157 Yuma 110 115 121 123 125 122 Arizona Total 192 197 199 201 194 190 Urban Counties 216 221 223 225 218 214 Rural-Urban Counties 154 162 166 168 162 162 Rural-Rural Counties 101 106 105 105 100 96 Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. 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 480 526 46 10% Small Rural Town 315 333 18 6% Isolated Small Rural Town 53 54 1 2% Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. 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 2002 2003 2004 2005 2006 2007 Arizona Total 192 197 199 203 197 194 Urban 209 214 216 220 215 211 Large Rural Town 125 131 129 128 124 118 Small Rural Town 88 90 87 90 88 88 Isolated Small Rural Town 53 59 60 59 51 59 Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. Population estimates provided by Nielsen-Claritas. 3-15

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 6 5-1 -17% Cochise 27 26-1 -4% Coconino 16 24 8 50% Gila 6 15 9 150% Graham 2 7 5 250% Greenlee 1 0-1 -100% La Paz 4 6 2 50% Maricopa 782 1,046 264 34% Mohave 42 62 20 48% Navajo 19 24 5 26% Pima 170 187 17 10% Pinal 22 23 1 5% Santa Cruz 2 2 0 0% Yavapai 36 47 11 31% Yuma 17 19 2 12% Arizona - Total 1,152 1,493 341 30% Urban Counties 952 1,233 281 30% Rural-Urban Counties 33 43 10 30% Rural-Rural Counties 167 217 50 30% Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Table 3.10. Total Osteopathic Physicians (DOs) per 100,000 Population: Arizona County Changes between 2002 and 2006 County 2002 2003 2004 2005 2006 Apache 9 7 9 9 7 Cochise 23 24 23 22 21 Coconino 13 14 14 15 19 Gila 12 12 24 20 29 Graham 6 6 9 9 21 Greenlee 13 14 0 0 0 La Paz 21 21 25 25 30 Maricopa 24 25 26 27 28 Mohave 25 26 31 33 32 Navajo 19 21 23 22 22 Pima 19 20 20 20 20 Pinal 11 11 12 11 9 Santa Cruz 5 10 7 7 5 Yavapai 20 23 27 26 23 Yuma 10 11 10 11 10 Arizona Total 21 22 23 24 24 Urban Counties 23 24 25 25 26 Rural-Urban Counties 12 12 12 13 14 Rural-Rural Counties 17 18 21 20 19 Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Population estimates provided by the U.S. Census Bureau. 3-16

Table 3.11. 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 1,493 341 30% Urban 1,009 1,305 296 29% Large Rural Town 76 108 32 42% Small Rural Town 59 73 14 24% Isolated Small Rural Town 8 7-1 -13% Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Table 3.12. Total Osteopathic Physicians (DOs) per 100,000 Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA 2002 2003 2004 2005 2006 Arizona Total 21 22 23 24 25 Urban 22 23 24 25 25 Large Rural Town 20 21 24 23 25 Small Rural Town 16 17 21 21 19 Isolated Small Rural Town 8 9 5 6 7 Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Population estimates provided by Nielsen-Claritas. Table 3.13. 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 26 20-6 -23% Cochise 60 64 4 7% Coconino 88 97 9 10% Gila 31 35 4 13% Graham 21 24 3 14% Greenlee 4 4 0 0% La Paz 10 11 1 10% Maricopa 2,369 2,855 486 21% Mohave 68 87 19 28% Navajo 60 64 4 7% Pima 716 797 81 11% Pinal 82 109 27 33% Santa Cruz 20 18-2 -10% Yavapai 114 140 26 23% Yuma 75 99 24 32% Arizona Total 3,744 4,424 680 18% Urban Counties 3,085 3,652 567 18% Rural-Urban Counties 163 196 33 20% Rural-Rural Counties 496 576 80 16% 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, 2002-2006. 3-17

Table 3.14. Primary Care Physicians (MDs and DOs) per 100,000 Population: Arizona County Changes between 2002 and 2006 County 2002 2003 2004 2005 2006 Apache 39 41 32 35 29 Cochise 50 54 53 53 50 Coconino 73 79 84 83 77 Gila 61 65 67 65 68 Graham 63 64 74 79 72 Greenlee 52 54 41 55 54 La Paz 52 51 61 55 55 Maricopa 72 75 77 77 76 Mohave 41 44 45 45 45 Navajo 59 60 62 61 59 Pima 82 84 86 87 84 Pinal 42 43 43 42 41 Santa Cruz 51 51 47 49 43 Yavapai 64 67 70 71 68 Yuma 45 48 50 52 53 Arizona - Total 69 72 74 74 72 Urban Counties 74 77 79 79 77 Rural-Urban Counties 57 61 64 65 63 Rural-Rural Counties 51 53 53 53 51 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. Table 3.15. 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 23 18-5 -22% Cochise 45 49 4 9% Coconino 79 83 4 5% Gila 26 27 1 4% Graham 19 19 0 0% Greenlee 3 4 1 33% La Paz 7 8 1 14% Maricopa 1,934 2,277 343 18% Mohave 53 63 10 19% Navajo 47 46-1 -2% Pima 625 691 66 11% Pinal 64 92 28 44% Santa Cruz 18 16-2 -11% Yavapai 94 119 25 27% Yuma 63 86 23 37% Arizona Total 3,100 3,598 498 16% Urban Counties 2,559 2,968 409 16% Rural-Urban Counties 142 169 27 19% Rural-Rural Counties 399 461 62 16% Source: Allopathic Physician Statistical Files, 2002-2006. 3-18

Table 3.16. 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 3 2-1 -33% Cochise 15 15 0 0% Coconino 9 14 5 56% Gila 5 8 3 60% Graham 2 5 3 150% Greenlee 1 0-1 -100% La Paz 3 3 0 0% Maricopa 435 578 143 33% Mohave 15 24 9 60% Navajo 13 18 5 38% Pima 91 106 15 16% Pinal 18 17-1 -6% Santa Cruz 2 2 0 0% Yavapai 20 21 1 5% Yuma 12 13 1 8% Arizona Total 644 826 182 28% Urban Counties 526 684 158 30% Rural-Urban Counties 21 27 6 29% Rural-Rural Counties 97 115 18 19% Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Table 3.17. 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 4,424 680 18% Urban 3,300 3,929 629 19% Large Rural Town 212 253 41 19% Small Rural Town 187 195 8 4% Isolated Small Rural Town 45 47 2 4% 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, 2002-2006. Table 3.18. Primary Care Physicians (MDs and DOs) per 100,000 Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA 2002 2003 2004 2005 2006 Arizona Total 69 72 74 75 73 Urban 72 75 77 78 76 Large Rural Town 55 59 60 59 60 Small Rural Town 52 52 53 54 51 Isolated Small Rural Town 45 50 48 49 45 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, 2002-2006. Population estimates provided by Nielsen-Claritas. 3-19

Table 3.19. 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 19 14-5 -26% Cochise 85 83-2 -2% Coconino 188 199 11 6% Gila 41 40-1 -2% Graham 8 9 1 13% Greenlee 3 4 1 33% La Paz 7 7 0 0% Maricopa 5,058 5,939 881 17% Mohave 164 210 46 28% Navajo 50 55 5 10% Pima 1,824 1,944 120 7% Pinal 68 88 20 29% Santa Cruz 13 16 3 23% Yavapai 206 245 39 19% Yuma 125 152 27 22% Arizona Total 7,859 9,005 1,146 15% Urban Counties 6,882 7,883 1,001 15% Rural-Urban Counties 313 351 38 12% Rural-Rural Counties 664 771 107 16% 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, 2002-2006. Table 3.20. Total Physician Specialists (MDs and DOs) per 100,000 Population: Arizona County Changes between 2002 and 2006 County 2002 2003 2004 2005 2006 Apache 28 25 19 19 20 Cochise 71 71 70 68 65 Coconino 156 164 160 165 158 Gila 80 77 89 86 78 Graham 24 15 15 18 27 Greenlee 39 27 27 14 54 La Paz 36 31 36 35 35 Maricopa 153 156 157 160 157 Mohave 99 104 104 107 110 Navajo 49 52 48 50 50 Pima 208 214 212 217 205 Pinal 34 39 44 40 33 Santa Cruz 33 38 30 34 38 Yavapai 115 125 129 128 119 Yuma 75 77 81 83 82 Arizona - Total 144 148 148 151 146 Urban Counties 165 168 169 171 167 Rural-Urban Counties 109 113 113 116 113 Rural-Rural Counties 68 71 72 72 68 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. 3-20

Table 3.21. 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 16 11-5 -31% Cochise 73 72-1 -1% Coconino 181 189 8 4% Gila 40 33-7 -18% Graham 8 7-1 -13% Greenlee 3 4 1 33% La Paz 6 4-2 -33% Maricopa 4,711 5,471 760 16% Mohave 137 172 35 26% Navajo 44 49 5 11% Pima 1,745 1,863 118 7% Pinal 64 82 18 28% Santa Cruz 13 16 3 23% Yavapai 190 219 29 15% Yuma 120 146 26 22% Arizona Total 7,351 8,338 987 13% Urban Counties 6,456 7,334 878 14% Rural-Urban Counties 301 335 34 11% Rural-Rural Counties 594 669 75 13% Source: Arizona Board of Medical Examiners Allopathic Physician Files 2008. Table 3.22. 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 3 3 0 0% Cochise 12 11-1 -8% Coconino 7 10 3 43% Gila 1 7 6 600% Graham 0 2 2 NA Greenlee 0 0 0 NA La Paz 1 3 2 200% Maricopa 347 468 121 35% Mohave 27 38 11 41% Navajo 6 6 0 0% Pima 79 81 2 3% Pinal 4 6 2 50% Santa Cruz 0 0 0 NA Yavapai 16 26 10 63% Yuma 5 6 1 20% Arizona Total 508 667 159 31% Urban Counties 426 549 123 29% Rural-Urban Counties 12 16 4 33% Rural-Rural Counties 70 102 32 46% Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. 3-21

Table 3.23. 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 344 381 37 11% Small Rural Town 187 211 24 13% Isolated Small Rural Town 16 14-2 -13% 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, 2002-2006. Table 3.24. Specialist Physicians (MDs and DOs) per 100,000 Population: Arizona s Four Rural- Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA 2002 2003 2004 2005 2006 Arizona Total 145 148 148 152 149 Urban 159 162 163 167 164 Large Rural Town 89 93 93 92 90 Small Rural Town 52 55 54 57 55 Isolated Small Rural Town 16 18 17 15 13 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, 2002-2006. Population estimates provided by Nielsen-Claritas. Table 3.25. 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 5 5 0 0% Cochise 10 10 0 0% Coconino 23 21-2 -9% Gila 7 5-2 -29% Graham 2 4 2 100% Greenlee 0 0 0 NA La Paz 0 1 1 NA Maricopa 456 498 42 9% Mohave 20 21 1 5% Navajo 10 9-1 -10% Pima 131 132 1 1% Pinal 8 11 3 38% Santa Cruz 4 4 0 0% Yavapai 13 19 6 46% Yuma 12 12 0 0% Arizona Total 701 752 51 7% Urban Counties 587 630 43 7% Rural-Urban Counties 35 33-2 -6% Rural-Rural Counties 79 89 10 13% 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, 2002-2006. 3-22

Table 3.26. 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 2002 2003 2004 2005 2006 Apache 36 43 36 36 35 Cochise 45 44 48 48 44 Coconino 80 90 90 87 74 Gila 83 60 73 73 60 Graham 31 32 48 48 62 Greenlee 0 0 0 0 0 La Paz 0 0 0 0 37 Maricopa 64 65 67 66 64 Mohave 72 69 69 66 63 Navajo 49 48 47 46 41 Pima 70 71 71 69 68 Pinal 23 27 28 23 22 Santa Cruz 49 61 60 59 47 Yavapai 44 49 57 60 54 Yuma 38 34 39 35 34 Arizona Total 62 63 65 63 60 Urban Counties 65 66 68 67 64 Rural-Urban Counties 58 60 63 59 52 Rural-Rural Counties 45 46 48 47 43 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. Table 3.27. 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 3 3 0 0% Cochise 7 7 0 0% Coconino 23 21-2 -9% Gila 7 5-2 -29% Graham 2 3 1 50% Greenlee 0 0 0 NA La Paz 0 1 1 NA Maricopa 418 448 30 7% Mohave 15 16 1 7% Navajo 8 7-1 -13% Pima 128 129 1 1% Pinal 6 9 3 50% Santa Cruz 4 4 0 0% Yavapai 13 19 6 46% Yuma 12 12 0 0% Arizona Total 646 684 38 6% Urban Counties 546 577 31 6% Rural-Urban Counties 35 33-2 -6% Rural-Rural Counties 65 74 9 14% Source: Allopathic Physician Statistical Files, 2002-2006. 3-23

Table 3.28. 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 2 2 0 0% Cochise 3 3 0 0% Coconino 0 0 0 NA Gila 0 0 0 NA Graham 0 1 1 NA Greenlee 0 0 0 NA La Paz 0 0 0 NA Maricopa 38 50 12 32% Mohave 5 5 0 0% Navajo 2 2 0 0% Pima 3 3 0 0% Pinal 2 2 0 0% Santa Cruz 0 0 0 NA Yavapai 0 0 0 NA Yuma 0 0 0 NA Arizona Total 55 68 13 24% Urban Counties 41 53 12 29% Rural-Urban Counties 0 0 0 NA Rural-Rural Counties 14 15 1 7% Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Table 3.29. 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 701 752 51 7% Urban 625 672 47 8% Large Rural Town 43 45 2 5% Small Rural Town 33 34 1 3% Isolated Small Rural Town 0 1 1 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, 2002-2006. Table 3.30. 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 2002 2003 2004 2005 2006 Arizona Total 62 63 64 63 61 Urban 64 65 67 65 63 Large Rural Town 62 62 67 64 59 Small Rural Town 49 48 49 50 47 Isolated Small Rural Town 0 0 5 5 5 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, 2002-2006. Population estimates provided by Nielsen-Claritas. 3-24

Table 3.31. 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 1 1 0 0% Cochise 8 7-1 -13% Coconino 20 20 0 0% Gila 1 1 0 0% Graham 0 0 0 NA Greenlee 0 1 1 NA La Paz 0 0 0 NA Maricopa 404 444 40 10% Mohave 9 11 2 22% Navajo 5 2-3 -60% Pima 171 183 12 7% Pinal 8 10 2 25% Santa Cruz 0 0 0 NA Yavapai 22 26 4 18% Yuma 9 6-3 -33% Arizona - Total 658 712 54 8% Urban Counties 575 627 52 9% Rural-Urban Counties 29 26-3 -10% Rural-Rural Counties 54 59 5 9% Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, 2002-2006. Table 3.32. Psychiatric Physicians (MD and DO): per 100,000 Population: Arizona County Changes between 2002 and 2006 County 2002 2003 2004 2005 2006 Apache 1 1 1 1 1 Cochise 7 7 6 6 6 Coconino 17 16 17 18 16 Gila 2 2 4 4 2 Graham 0 0 0 0 0 Greenlee 0 0 0 0 13 La Paz 0 0 0 0 0 Maricopa 12 12 12 13 12 Mohave 5 5 6 5 6 Navajo 5 6 2 2 2 Pima 19 20 20 20 19 Pinal 4 5 7 7 4 Santa Cruz 0 0 0 0 0 Yavapai 12 14 15 14 13 Yuma 5 6 6 6 3 Arizona Total 12 12 12 13 12 Urban Counties 14 14 14 14 13 Rural-Urban Counties 10 10 10 10 8 Rural-Rural Counties 6 6 6 6 5 Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, 2002-2006. Population estimates provided by the U.S. Census Bureau. 3-25

Table 3.33. 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 658 712 54 8% Urban 624 674 50 8% Large Rural Town 18 22 4 22% Small Rural Town 15 15 0 0% Isolated Small Rural Town 1 1 0 0% Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, 2002-2006. Table 3.34. Psychiatric Physicians (MD and DO) per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA 2002 2003 2004 2005 2006 Arizona Total 12 12 12 13 12 Urban 14 14 14 14 13 Large Rural Town 5 5 6 6 5 Small Rural Town 4 5 4 4 4 Isolated Small Rural Town 1 1 4 3 1 Source: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Psychiatric Physician Statistical Files, 2002-2006. Population estimates provided by Nielsen-Claritas. Table 3.35. 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 69.5 41.9 27.6 Rural-Urban 64.8 54.6 10.2 Rural-Rural 45.2 37.0 8.2 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 3.36. 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 64.8 39.9 24.9 Large rural town 49.2 41.0 8.2 Small rural town 56.4 47.9 8.5 Isolated small rural town 28.1 22.7 5.4 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

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 100,000. 2 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 2006 100,000, 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: 2002-2007 Figure 4.2. Physician Assistants per 100,000 Population Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: 2002-2007 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, 2002-2006. 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. 4-1

Figure 4.3. Physician Assistant Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Figure 4.4. Physician Assistants per 100,000 Population Profilefor Arizona s Four Rural Urban Commuting Areas: 2002-2007 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, 2002-2006. 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, 2002-2006. 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 2007. The state wide number of PAs per 100,000 population increased from 17 in 2002 to 23 in 2007. 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. 1-152. 2. The New York Center for Health Workforce Studies (2006). The United States Workforce Profile, Health Resources and Services Administration, DHHS. pp. 1-159. 4-2

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 16 10-6 -38% Cochise 20 19-1 -5% Coconino 34 41 7 21% Gila 12 10-2 -17% Graham 10 12 2 20% Greenlee 7 4-3 -43% La Paz 3 2-1 -33% Maricopa 593 1,011 418 70% Mohave 40 56 16 40% Navajo 16 20 4 25% Pima 85 141 56 66% Pinal 27 46 19 70% Santa Cruz 2 1-1 -50% Yavapai 22 42 20 91% Yuma 27 40 13 48% Arizona - Total 914 1,455 541 59% Urban Counties 678 1,152 474 70% Rural-Urban Counties 61 81 20 33% Rural-Rural Counties 175 222 47 27% 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, 2002-2006. Table 4.2. Physician Assistants per 100,000 Population: Arizona County Changes between 2002-2007 County 2002 2003 2004 2005 2006 2007 Apache 24 25 26 22 13 14 Cochise 17 16 16 15 17 15 Coconino 28 33 30 29 32 32 Gila 23 20 16 18 17 19 Graham 30 21 28 27 30 35 Greenlee 91 108 55 55 27 52 La Paz 16 15 15 15 10 10 Maricopa 18 20 22 21 24 26 Mohave 24 23 25 25 27 29 Navajo 16 15 16 15 17 18 Pima 10 11 12 12 14 15 Pinal 14 16 18 16 16 15 Santa Cruz 5 5 5 5 2 2 Yavapai 12 13 15 14 18 20 Yuma 16 19 20 21 22 21 Arizona Total 17 19 20 19 22 23 Urban Counties 16 18 20 19 22 24 Rural-Urban Counties 21 25 24 24 26 25 Rural-Rural Counties 18 18 19 18 18 19 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, 2002-2006. Population estimates provided by the U.S. Census Bureau. 4-3

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 1,455 541 59% Urban 741 1,259 518 70% Large Rural Town 81 105 24 30% Small Rural Town 82 79-3 -4% Isolated Small Rural Town 10 12 2 20% 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, 2002-2006. Table 4.4. Physician Assistants per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA 2002 2003 2004 2005 2006 2007 Arizona Total 17 19 20 19 22 23 Urban 16 18 20 19 22 24 Large Rural Town 21 19 20 20 23 24 Small Rural Town 23 25 25 22 20 20 Isolated Small Rural Town 10 10 12 12 11 11 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, 2002-2006. Population estimates provided by Nielsen-Claritas. 4-4

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 2004. 2 Arizona had 678 RNs per 100,000 population while the US average was 802 per 100,000. 2 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: 2002-2007 Figure 5.2. Registered Nurses (RNs) per 100,000 Population Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: 2002-2007 Source: Arizona Board of Nursing, Registered Nurses File 2008. Source: Arizona Board of Nursing, Registered Nurses File 2008. Population estimates provided by the U.S. Census Bureau 5-1

declined from 866 per 100,000 in 2004 to 837 per 100,000 in 2007. Pima County declined from 1,022 per 100,000 in 2004 to 985 per 100,000 in 2007. 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 2007. 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 2002. 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: 2002-2007 Figure 5.4. Registered Nurses (RNs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Source: Arizona Board of Nursing, Registered Nurses File 2008. Figure 5.5. Certified Registered Nurse Anesthetist (CRNA) Profile for Arizona and Urban/Rural-Urban/Rural- Rural Counties: 2002-2007 Source: Arizona Board of Nursing, Registered Nurses File 2008. 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: 2002-2007 Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File 2008. 5-2 Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File 2008. Population estimates provided by the U.S. Census Bureau.

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 2007. 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: 2002-2007 Figure 5.8. Certified Registered Nurse Anesthetists (CRNAs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File 2008. Figure 5.9. Nurse Practitioner (NP) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File 2008. Population estimates provided by Claritas. Figure 5.10. Nurse Practitioners (NPs) per 100,000 Population Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: 2002-2007 Source: Arizona Board of Nursing, Nurse Practitioners File 2008 Source: Arizona Board of Nursing, Nurse Practitioners File 2008. Population estimates provided by the U.S. Census Bureau. 5-3

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 5.12. 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 5.12. 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 2007. 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 5.11. Nurse Practitioner (NP) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Figure 5.12. Nurse Practitioners (NPs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Source: Arizona Board of Nursing, Nurse Practitioners File 2008. 5-4 Source: Arizona Board of Nursing, Nurse Practitioners File 2008. Population estimates provided by Claritas.

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 2007. 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 5.16. 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 2007. 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 5.13. Certified Nurse Midwife (CNM) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.14. 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: 2002-2007 Source: Arizona Board of Nursing, Certified Midwives File 2008. Source: Arizona Board of Nursing, Certified Nurse Midwives File 2008. Population estimates provided by the U.S. Census Bureau Figure 5.15. Certified Nurse Midwife (CNM) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Figure 5.16. 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: 2002-2007 Source: Arizona Board of Nursing, Certified Nurse Midwives File 2008. Source: Arizona Board of Nursing, Certified Nurse Midwives File 2008. Population estimates provided by Claritas. 5-5

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 5.20. 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 2007. There were 20,518 CNAs in Arizona in 2007. State wide there was as 12% increase in number of CNAs (+2,196) from 2002 to 2007 but a decrease in Figure 5.17. Licensed Practical Nurse (LPN) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.18. Licensed Practical Nurses (LPNs) per 100,000 Population Profile for Arizona and Urban/ Rural-Urban/Rural-Rural Counties: 2002-2007 Source: Arizona Board of Nursing Licensed Practical Nurses File 2008. Figure 5.19. Licensed Practical Nurse (LPN) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Source: Arizona Board of Nursing Licensed Practical Nurses File 2008. Population estimates provided by the U.S. Census Bureau. Figure 5.20. Licensed Practical Nurses (LPNs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Source: Arizona Board of Nursing Licensed Practical Nurses File 2008 Source: Arizona Board of Nursing Licensed Practical Nurses File 2008. Population estimates provided by Claritas. 5-6

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 5.24. 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 5.24. Figure 5.21. Certified Nurse Assistant (CNA) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.22. Certified Nurse Assistants (CNAs) per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: 2002-2007 Source: Arizona Board of Nursing, Certified Nurse Assistants File 2008. Figure 5.23. Certified Nurse Assistant (CNA) Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Source: Arizona Board of Nursing, Certified Nurse Assistants File 2008. Population estimates provided by the U.S. Census Bureau. Figure 5.24. Certified Nurse Assistants (CNAs) per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Source: Arizona Board of Nursing, Certified Nurse Assistants File 2008. Source: Arizona Board of Nursing, Certified Nurse Assistants File 2008. Population estimates provided by Claritas. 5-7

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. 5 5.2 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 2007. 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 2007. The largest number of certified registered nurse anesthetists (78.9%) was located in the urban classified counties in 2007. 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 2007. Wide inequalities in the distribution of NPpopulation ratios were apparent between the urban and rural areas from 2002 to 2007. 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 2007. No CNMs were reported in Greenlee, La Paz, Gila and Cochise counties in 2007. There were 2.2 times more CNAs (20,518) than LPNs (9,241) in 2007. 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. 1-152. 2. The New York Center for Health Workforce Studies (2006). The United States Workforce Profile, Health Resources and Services Administration, DHHS. pp. 1-159. 3. The Center for Health Information & Research (CHIR) (2009). The Arizona Health Care Workforce: Nurses, Pharmacists, & Physician Assistant. pp. 1-120. 4. Wikipedia, Certified Nursing Assistant (2010). Retrieved on March 30, 2010 on the World Wide Web: http://en.wikipedia.org/wiki/certified_ Nursing_Assistant. 5. Johnson WG, Wilson B, Edge M, Qiu Y, Oliver EL, and Russell K. 2009. The Arizona Health Care Workforce: Nurses, Pharmacists, & Physician Assistants. Center for Health Information and Research, Arizona State University, Tempe. pp 134. 5-8

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 2007 2002 to 2007 Apache 219 282 63 29% Cochise 815 897 82 10% Coconino 1,133 1,386 253 22% Gila 353 364 11 3% Graham 175 226 51 29% Greenlee 26 28 2 8% La Paz 56 60 4 7% Maricopa 27,649 32,487 4,838 17% Mohave 1,122 1,408 286 25% Navajo 582 660 78 13% Pima 8,521 9,527 1,006 12% Pinal 1,116 1,814 698 63% Santa Cruz 108 137 29 27% Yavapai 1,811 2,075 264 15% Yuma 820 1,044 224 27% Arizona - Total 44,506 52,395 7,889 18% Urban Counties 36,170 42,014 5,844 16% Rural-Urban Counties 1,953 2,430 477 24% Rural-Rural Counties 6,383 7,951 1,568 25% Source: Arizona Board of Nursing, Registered Nurses File 2008. Table 5.2. Registered Nurses (RNs) per 100,000 Population: Arizona County Changes between 2002 and 2007 County 2002 2003 2004 2005 2006 2007 Apache 326 344 374 391 400 403 Cochise 680 703 721 714 696 702 Coconino 941 1,016 1,059 1,058 1,053 1,087 Gila 690 718 720 704 700 700 Graham 529 549 568 591 612 650 Greenlee 337 352 260 301 321 361 La Paz 290 282 295 301 290 297 Maricopa 838 855 866 846 837 837 Mohave 679 708 715 709 693 722 Navajo 574 590 604 591 595 593 Pima 971 1,002 1,022 1,009 997 985 Pinal 566 591 610 622 644 606 Santa Cruz 275 293 293 299 314 320 Yavapai 1,015 1,035 1,043 1,006 989 976 Yuma 493 521 546 539 546 548 Arizona Total 817 840 853 837 829 827 Urban Counties 866 886 898 879 869 867 Rural-Urban Counties 681 728 758 751 751 764 Rural-Rural Counties 651 674 688 683 682 678 Source: Arizona Board of Nursing, Registered Nurses File 2008. Population estimates provided by the U.S. Census Bureau. 5-9

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 3,051 434 17% Small Rural Town 1,836 2,120 284 15% Isolated Small Rural Town 392 428 36 9% Source: Arizona Board of Nursing, Registered Nurses File 2008. Table 5.4. Registered Nurses (RNs) per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA 2002 2003 2004 2005 2006 2007 Arizona Total 819 838 854 846 846 845 Urban 864 883 899 890 890 888 Large Rural Town 680 695 706 701 694 704 Small Rural Town 513 534 547 544 543 549 Isolated Small Rural Town 390 407 392 390 400 401 Source: Arizona Board of Nursing,Registered Nurses File 2008. 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 2007 2002 to 2007 Apache 0 0 0 NA Cochise 5 6 1 20% Coconino 4 6 2 50% Gila 6 6 0 0% Graham 2 4 2 100% Greenlee 0 0 0 NA La Paz 2 1-1 -50% Maricopa 78 167 89 114% Mohave 1 4 3 300% Navajo 3 5 2 67% Pima 12 16 4 33% Pinal 1 3 2 200% Santa Cruz 0 1 1 NA Yavapai 5 13 8 160% Yuma 0 0 0 NA Arizona Total 119 232 113 95% Urban Counties 90 183 93 103% Rural-Urban Counties 4 6 2 50% Rural-Rural Counties 25 43 18 72% Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File 2008. 5-10

Table 5.6. Certified Registered Nurse Anesthetist (CRNAs) per 100,000 Population: Arizona County Changes between 2002 and 2007 County 2002 2003 2004 2005 2006 2007 Apache 0 0 0 0 0 0 Cochise 4 5 5 5 5 5 Coconino 3 4 4 5 5 5 Gila 12 12 10 12 10 12 Graham 6 6 9 9 12 12 Greenlee 0 0 0 0 0 0 La Paz 10 10 5 5 5 5 Maricopa 2 3 3 3 4 4 Mohave 1 1 1 1 2 2 Navajo 3 4 5 6 5 4 Pima 1 2 2 2 2 2 Pinal 1 0 0 0 0 1 Santa Cruz 0 3 2 2 2 2 Yavapai 3 3 4 4 6 6 Yuma 0 0 0 0 0 0 Arizona Total 2 3 3 3 3 4 Urban Counties 2 3 3 3 3 4 Rural-Urban Counties 1 2 2 2 2 2 Rural-Rural Counties 3 3 3 3 4 4 Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File 2008. 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 119 232 113 95% Urban 91 188 97 107% Large Rural Town 14 28 14 100% Small Rural Town 11 13 2 18% Isolated Small Rural Town 3 3 0 0% Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File 2008. 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 2002 2003 2004 2005 2006 2007 Arizona Total 2 3 3 3 3 4 Urban 2 2 3 3 3 4 Large Rural Town 4 4 4 5 6 6 Small Rural Town 3 3 3 4 3 3 Isolated Small Rural Town 3 3 3 3 3 3 Source: Arizona Board of Nursing, Certified Registered Nurse Anesthetist File 2008. Population estimates provided by Nielsen-Claritas. 5-11

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 8 16 8 100% Cochise 31 39 8 26% Coconino 59 92 33 56% Gila 10 14 4 40% Graham 2 6 4 200% Greenlee 0 0 0 NA La Paz 2 3 1 50% Maricopa 916 1,382 466 51% Mohave 25 38 13 52% Navajo 20 31 11 55% Pima 340 483 143 42% Pinal 20 61 41 205% Santa Cruz 6 9 3 50% Yavapai 51 85 34 67% Yuma 22 35 13 59% Arizona - Total 1,512 2,294 782 52% Urban Counties 1,256 1,865 609 48% Rural-Urban Counties 81 127 46 57% Rural-Rural Counties 175 302 127 73% Source: Arizona Board of Nursing, Nurse Practitioners File 2008. Table 5.10. Nurse Practitioners (NPs) per 100,000 Population: Arizona County Changes between 2002 and 2007 County 2002 2003 2004 2005 2006 2007 Apache 12 13 15 16 17 23 Cochise 26 26 27 27 30 31 Coconino 49 54 59 61 68 72 Gila 20 16 16 22 25 27 Graham 6 6 9 9 15 17 Greenlee 0 0 0 0 0 0 La Paz 10 10 10 15 15 15 Maricopa 28 29 31 32 34 36 Mohave 15 16 17 18 20 19 Navajo 20 21 24 21 24 28 Pima 39 41 44 46 48 50 Pinal 10 12 13 17 21 20 Santa Cruz 15 18 17 19 21 21 Yavapai 29 29 32 35 36 40 Yuma 13 14 14 14 18 18 Arizona Total 28 29 31 33 34 36 Urban Counties 30 32 33 35 36 38 Rural-Urban Counties 28 31 33 33 38 40 Rural-Rural Counties 18 19 20 22 24 26 Source: Arizona Board of Nursing, Nurse Practitioners File 2008. Population estimates provided by the U.S. Census Bureau. 5-12

Table 5.11. 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 2,294 782 52% Urban 1,372 2,079 707 52% Large Rural Town 71 109 38 54% Small Rural Town 50 77 27 54% Isolated Small Rural Town 19 29 10 53% Source: Arizona Board of Nursing, Nurse Practitioners File 2008. Table 5.12. Nurse Practitioners (NPs) per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA 2002 2003 2004 2005 2006 2007 Arizona Total 28 29 31 33 35 37 Urban 30 31 33 35 37 39 Large Rural Town 18 18 19 21 24 25 Small Rural Town 14 15 17 17 18 20 Isolated Small Rural Town 19 22 22 20 25 27 Source: Arizona Board of Nursing, Nurse Practitioners File 2008. Population estimates provided by Nielsen-Claritas. Table 5.13. 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 4 5 1 25% Cochise 1 0-1 -100% Coconino 7 8 1 14% Gila 0 0 0 NA Graham 1 1 0 0% Greenlee 0 0 0 NA La Paz 0 0 0 NA Maricopa 56 64 8 14% Mohave 3 2-1 -33% Navajo 7 7 0 0% Pima 49 55 6 12% Pinal 2 1-1 -50% Santa Cruz 0 1 1 NA Yavapai 3 4 1 33% Yuma 7 8 1 14% Arizona Total 140 156 16 11% Urban Counties 105 119 14 13% Rural-Urban Counties 14 16 2 14% Rural-Rural Counties 21 21 0 0% Source: Arizona Board of Nursing, Certified Midwives File 2008. 5-13

Table 5.14. Certified Nurse Midwives (CNMs) per 100,000 Women of Child Bearing Age (15 44 y/o): Arizona County Changes Between 2002 and 2007 County 2002 2003 2004 2005 2006 2007 Apache 29 28 36 36 35 35 Cochise 4 4 4 4 4 0 Coconino 24 24 21 28 28 28 Gila 0 0 0 0 0 0 Graham 16 16 16 16 16 15 Greenlee 0 0 0 0 0 0 La Paz 0 0 0 0 0 0 Maricopa 8 8 8 8 8 8 Mohave 11 10 13 9 9 6 Navajo 34 34 33 32 32 31 Pima 26 26 27 27 27 28 Pinal 6 5 5 5 2 2 Santa Cruz 0 0 12 12 12 12 Yavapai 10 10 9 12 11 11 Yuma 22 21 24 23 23 23 Arizona Total 12 12 13 13 12 12 Urban Counties 12 12 12 12 12 12 Rural-Urban Counties 23 23 23 25 25 25 Rural-Rural Counties 12 12 13 12 11 10 Source: Arizona Board of Nursing, Certified Nurse Midwives File 2008. Population estimates provided by the U.S. Census Bureau Table 5.15. 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 140 156 16 11% Urban 122 138 16 13% Large Rural Town 3 3 0 0% Small Rural Town 14 13-1 -7% Isolated Small Rural Town 1 2 1 100% Source: Arizona Board of Nursing, Certified Nurse Midwives File 2008. Table 5.16. 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 2002 2003 2004 2005 2006 2007 Arizona Total 12 12 13 13 13 12 Urban 12 12 13 13 13 13 Large Rural Town 4 4 5 4 4 4 Small Rural Town 21 20 22 23 21 18 Isolated Small Rural Town 5 5 10 10 10 10 Source: Arizona Board of Nursing, Certified Nurse Midwives File 2008. Population estimates provided by Nielsen-Claritas. 5-14

Table 5.17. 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 37 46 9 24% Cochise 177 210 33 19% Coconino 72 87 15 21% Gila 97 114 17 18% Graham 22 32 10 45% Greenlee 9 13 4 44% La Paz 11 16 5 45% Maricopa 4,065 5,535 1,470 36% Mohave 198 253 55 28% Navajo 85 104 19 22% Pima 1,482 1,805 323 22% Pinal 332 498 166 50% Santa Cruz 40 48 8 20% Yavapai 250 294 44 18% Yuma 126 186 60 48% Arizona Total 7,003 9,241 2,238 32% Urban Counties 5,547 7,340 1,793 32% Rural-Urban Counties 198 273 75 38% Rural-Rural Counties 1,258 1,628 370 29% Source: Arizona Board of Nursing Licensed Practical Nurses File 2008. Table 5.18. Licensed Practical Nurses (LPNs) per 100,000 Population: Arizona County Changes between 2002 and 2007 County 2002 2003 2004 2005 2006 2007 Apache 55 56 56 56 60 66 Cochise 148 136 140 156 159 164 Coconino 60 56 62 62 67 68 Gila 189 191 189 195 214 219 Graham 66 73 68 104 120 92 Greenlee 117 122 164 178 187 168 La Paz 57 51 66 75 80 79 Maricopa 123 122 126 131 137 143 Mohave 120 117 119 120 126 130 Navajo 84 78 88 88 99 93 Pima 169 172 179 182 185 187 Pinal 168 167 172 176 175 166 Santa Cruz 102 109 117 124 116 112 Yavapai 140 137 142 142 136 138 Yuma 76 75 77 86 91 98 Arizona Total 129 128 132 137 142 146 Urban Counties 133 133 137 141 147 151 Rural-Urban Counties 69 67 71 76 81 86 Rural-Rural Counties 128 126 131 136 140 139 Source: Arizona Board of Nursing Licensed Practical Nurses File 2008. Population estimates provided by the U.S. Census Bureau. 5-15

Table 5.19. 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 569 688 119 21% Small Rural Town 267 337 70 26% Isolated Small Rural Town 100 117 17 17% Source: Arizona Board of Nursing Licensed Practical Nurses File 2008. Table 5.20. Licensed Practical Nurses (LPNs) per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA 2002 2003 2004 2005 2006 2007 Arizona Total 129 128 132 138 145 149 Urban 132 132 136 142 149 154 Large Rural Town 148 142 143 150 157 159 Small Rural Town 75 73 77 82 88 87 Isolated Small Rural Town 99 99 101 105 109 110 Source: Arizona Board of Nursing Licensed Practical Nurses File 2008. Population estimates provided by Claritas. Table 5.21. 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 244 250 6 2% Cochise 450 520 70 16% Coconino 356 641 285 80% Gila 328 380 52 16% Graham 232 300 68 29% Greenlee 30 41 11 37% La Paz 41 26-15 -37% Maricopa 10,114 11,031 917 9% Mohave 603 775 172 29% Navajo 350 482 132 38% Pima 3,034 3,171 137 5% Pinal 916 1,063 147 16% Santa Cruz 151 166 15 10% Yavapai 825 951 126 15% Yuma 648 721 73 11% Arizona Total 18,322 20,518 2,196 12% Urban Counties 13,148 14,202 1,054 8% Rural-Urban Counties 1,004 1,362 358 36% Rural-Rural Counties 4,170 4,954 784 19% Source: Arizona Board of Nursing, Certified Nurse Assistants File 2008. 5-16

Table 5.22. Certified Nurse Assistants (CNAs) per 100,000 Population: Arizona County Changes Between 2002 and 2007 County 2002 2003 2004 2005 2006 2007 Apache 363 375 366 365 341 357 Cochise 376 400 394 421 405 407 Coconino 296 394 457 487 477 503 Gila 641 686 744 784 723 731 Graham 701 851 946 912 855 863 Greenlee 389 555 574 561 509 529 La Paz 212 200 168 150 125 129 Maricopa 306 320 321 322 294 284 Mohave 365 410 411 413 386 398 Navajo 345 386 416 431 399 433 Pima 346 359 362 364 337 328 Pinal 464 470 457 444 383 355 Santa Cruz 384 435 435 435 404 387 Yavapai 462 498 521 514 455 447 Yuma 389 384 386 388 366 378 Arizona Total 336 355 358 360 330 324 Urban Counties 315 328 329 331 302 293 Rural-Urban Counties 350 388 415 429 411 428 Rural-Rural Counties 426 459 467 468 425 422 Source: Arizona Board of Nursing, Certified Nurse Assistants File 2008. Population estimates provided by the U.S. Census Bureau. Table 5.23. 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 2,053 302 17% Small Rural Town 1,094 1,476 382 35% Isolated Small Rural Town 339 349 10 3% Source: Arizona Board of Nursing, Certified Nurse Assistants File 2008. Table 5.24. Certified Nurse Assistants (CNAs) per 100,000: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA 2002 2003 2004 2005 2006 2007 Arizona Total 337 354 359 364 337 331 Urban 330 343 347 351 324 316 Large Rural Town 455 494 510 514 476 474 Small Rural Town 306 347 353 368 352 382 Isolated Small Rural Town 337 349 348 366 332 327 Source: Arizona Board of Nursing, Certified Nurse Assistants File 2008. Population estimates provided by Nielsen-Claritas. 5-17

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 2006. 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 2004. 2 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 100,000. 2 This national study used data from the Kaiser Family Foundation www.statehealthfacts.org 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: 2002-2006 Figure 6.2. Total Dentists per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by the U.S. Census Bureau. 6-1

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 2006. 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: 2002-2006 Figure 6.4. Total Dentist per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Figure 6.5. General Dentist Profile for Arizona and Urban/ Rural- Urban/Rural-Rural Counties: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by Claritas. Figure 6.6. General Dentists per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. 6-2 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by the U.S. Census Bureau.

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 2006. 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: 2002-2006 Figure 6.8. General Dentist per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Figure 6.9. Specialist Dentist Profile for Arizona and Urban/ Rural- Urban/Rural-Rural Counties: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by Claritas. Figure 6.10. Specialist Dentists per 100,000 Population Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by the U.S. Census Bureau. 6-3

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 6.12. 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). 4 6.2 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 2006. Eighty-three percent of active license dentists were located in Maricopa and Figure 6.11. Specialist Dentist Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 6.12. Specialist Dentists per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. 6-4 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by Claritas.

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 2006. 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. 1-152. 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 2002. 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. 1-159. 3. Health Resources and Services Administration, Bureau of Health Professionals, Dental HSPA Designation Overview. (2009) Retrieved on October 29, 2010 from http://bhpr.hrsa.gov/shortage/dental. htm. 4. Mertz E, and Grumbach K. 2004. 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

Table 6.1. Number of Office Locations per Dentist in Arizona: 2002-2006 Year 1 2 3 4+ Total 2002 1,718 67% 609 24% 182 7% 74 3% 2,583 2003 1,767 65% 656 24% 187 7% 97 4% 2,707 2004 1,855 64% 680 24% 225 8% 119 4% 2,879 2005 1,979 63% 755 24% 251 8% 138 4% 3,123 2006 2,014 61% 841 25% 279 8% 178 5% 3,312 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. 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 12.33 18.00 5.67 46% Cochise 36.73 45.95 9.22 25% Coconino 70.77 78.50 7.73 11% Gila 18.78 19.87 1.09 6% Graham 14.67 15.50 0.83 6% Greenlee 2.17 1.50-0.67-31% La Paz 2.00 3.00 1.00 50% Maricopa 1,727.13 2,260.37 533.25 31% Mohave 55.07 70.08 15.02 27% Navajo 35.52 43.31 7.79 22% Pima 425.95 505.64 79.69 19% Pinal 41.25 69.74 28.49 69% Santa Cruz 7.50 9.00 1.50 20% Yavapai 96.50 124.03 27.53 29% Yuma 39.64 51.50 11.86 30% Arizona Total 2,586.00 3,316.00 730.00 28% Urban Counties 2,153.07 2,766.01 612.94 28% Rural-Urban Counties 110.41 130.00 19.59 18% Rural-Rural Counties 322.52 419.99 97.47 30% Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. 6-6

Table 6.3. Total Dentists per 100,000 Population: Arizona County Changes between 2002-2006 County 2002 2003 2004 2005 2006 Apache 18 15 17 16 26 Cochise 31 33 35 37 36 Coconino 59 56 58 58 62 Gila 37 43 47 47 39 Graham 44 48 43 45 46 Greenlee 28 29 30 30 20 La Paz 10 10 8 13 15 Maricopa 52 54 55 58 60 Mohave 33 34 36 38 37 Navajo 35 36 35 37 40 Pima 49 50 51 53 53 Pinal 21 21 22 25 26 Santa Cruz 19 23 22 22 21 Yavapai 54 54 54 58 60 Yuma 24 25 28 26 28 Arizona Total 47 49 50 53 54 Urban Counties 52 53 55 57 59 Rural-Urban Counties 38 38 40 39 42 Rural-Rural Counties 33 34 34 37 37 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. 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 3,316 730 28% Urban 2,317 2,993 676 29% Large Rural Town 134 165 32 24% Small Rural Town 114 136 21 19% Isolated Small Rural Town 21 22 1 6% Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Table 6.5. Total Dentists per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA 2002 2003 2004 2005 2006 Arizona Total 48 49 50 53 55 Urban 50 51 53 56 58 Large Rural Town 35 37 39 40 39 Small Rural Town 32 31 32 33 36 Isolated Small Rural Town 21 21 18 18 21 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by Nielsen-Claritas. 6-7

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 10.50 14.50 4.00 38% Cochise 29.70 36.70 7.00 24% Coconino 59.00 60.67 1.67 3% Gila 16.12 18.49 2.38 15% Graham 11.67 12.33 0.67 6% Greenlee 2.17 1.50-0.67-31% La Paz 2.00 2.50 0.50 25% Maricopa 1,444.69 1,820.98 376.29 26% Mohave 50.07 63.08 13.02 26% Navajo 29.87 35.06 5.19 17% Pima 349.33 409.37 60.04 17% Pinal 37.75 60.03 22.28 59% Santa Cruz 7.50 9.00 1.50 20% Yavapai 81.67 106.78 25.12 31% Yuma 31.98 42.00 10.02 31% Arizona Total 2,164.00 2,693.00 529.00 24% Urban Counties 1,794.02 2,230.35 436.32 24% Rural-Urban Counties 90.98 102.67 11.69 13% Rural-Rural Counties 279.00 359.99 80.99 29% Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Table 6.7. General Dentists per 100,000 Population: Arizona County Changes between 2002-2006 County 2002 2003 2004 2005 2006 Apache 16 13 15 14 21 Cochise 25 28 29 30 29 Coconino 49 46 46 44 48 Gila 31 38 42 40 36 Graham 35 39 34 36 37 Greenlee 28 29 30 30 20 La Paz 10 10 8 10 12 Maricopa 44 45 46 47 48 Mohave 30 31 33 34 33 Navajo 29 30 28 30 32 Pima 40 41 42 44 43 Pinal 19 20 20 22 22 Santa Cruz 19 23 22 22 21 Yavapai 46 47 46 49 52 Yuma 19 21 23 21 23 Arizona Total 40 41 42 43 44 Urban Counties 43 44 45 47 47 Rural-Urban Counties 32 31 33 31 33 Rural-Rural Counties 28 30 30 32 32 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by the U.S. Census Bureau. 6-8

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 2,693 529 24% Urban 1,932 2,418 486 25% Large Rural Town 115 140 25 21% Small Rural Town 98 115 17 18% Isolated Small Rural Town 19 21 2 10% Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Table 6.9. General Dentists per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA 2002 2003 2004 2005 2006 Arizona Total 40 41 42 44 45 Urban 42 43 44 46 47 Large Rural Town 30 33 34 35 33 Small Rural Town 27 26 28 28 30 Isolated Small Rural Town 19 19 16 16 19 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by Nielsen-Claritas. Table 6.10. 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 1.83 3.50 1.67 91% Cochise 7.03 9.25 2.22 32% Coconino 11.77 17.83 6.07 52% Gila 2.67 1.38-1.29-48% Graham 3.00 3.17 0.17 6% Greenlee 0.00 0.00 0.00 NA La Paz 0.00 0.50 0.50 NA Maricopa 282.43 439.39 156.96 56% Mohave 5.00 7.00 2.00 40% Navajo 5.65 8.25 2.60 46% Pima 76.62 96.27 19.65 26% Pinal 3.50 9.71 6.21 177% Santa Cruz 0.00 0.00 0.00 NA Yavapai 14.83 17.25 2.42 16% Yuma 7.67 9.50 1.83 24% Arizona Total 422.00 623.00 201.00 48% Urban Counties 359.05 535.66 176.61 49% Rural-Urban Counties 19.43 27.33 7.90 41% Rural-Rural Counties 43.52 60.00 16.49 38% Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. 6-9

Table 6.11. Dentist Specialists per 100,000 Population: Arizona County Changes between 2002 and 2006 County 2002 2003 2004 2005 2006 Apache 3 2 2 2 5 Cochise 6 5 6 6 7 Coconino 10 10 11 14 14 Gila 5 5 5 6 3 Graham 9 9 10 10 9 Greenlee 0 0 0 0 0 La Paz 0 0 0 3 2 Maricopa 9 9 10 11 12 Mohave 3 3 3 4 4 Navajo 6 6 7 7 8 Pima 9 9 9 10 10 Pinal 2 1 2 3 4 Santa Cruz 0 0 0 0 0 Yavapai 8 7 8 9 8 Yuma 5 5 5 4 5 Arizona - Total 8 8 9 9 10 Urban Counties 9 9 10 10 11 Rural-Urban Counties 7 7 7 8 9 Rural-Rural Counties 4 4 4 5 5 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by the U.S. Census Bureau. Table 6.12. 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 422 623 201 48% Urban 385 575 190 49% Large Rural Town 18 26 7 39% Small Rural Town 17 21 4 24% Isolated Small Rural Town 2 1-1 -100% Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Table 6.13. Dentist Specialists per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA 2002 2003 2004 2005 2006 Arizona Total 8 8 9 9 10 Urban 8 9 9 10 11 Large Rural Town 5 4 5 6 6 Small Rural Town 5 5 5 5 6 Isolated Small Rural Town 2 2 2 2 1 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006. Population estimates provided by Nielsen-Claritas. 6-10

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 2007. 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 100,000. 1 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 2007. 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: 2002-2007 Figure 7.2. Pharmacists per 100,000 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. Population estimates provided by the U.S. Census Bureau. 7-1

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 2004. 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 2007. 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 2004. 1 Arizona s 104.6 pharmacy technicians per 100,000 population was less than the U.S. average of 105.7 per 100,000. 1 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: 2002-2007 Figure 7.4. Pharmacists per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. 7-2 Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. Population estimates provided by Claritas.

Figure 7.5. Pharmacy Technician Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2004-2007 Figure 7.6. Pharmacy Technicians per 100,000 Population Profile for Arizona and Urban/Rural-Urban/ Rural-Rural Counties: 2004-2007 Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. Figure 7.7. Pharmacy Technician Profile for Arizona s Four Rural Urban Commuting Areas: 2004-2007 Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. 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: 2004-2007 Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. 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. 2 7.2 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 2007. 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

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 2007. 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. 1-159. 2. The Center for Health Information & Research (CHIR) (2009). The Arizona Health Care Workforce: Nurses, Pharmacists, & Physician Assistant. pp. 1-120. 7-4

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 2007 2002 to 2007 Apache 9 8-1 -11% Cochise 42 54 12 29% Coconino 70 91 21 30% Gila 26 32 6 23% Graham 12 16 4 33% Greenlee 0 0 0 NA La Paz 1 1 0 0% Maricopa 2,400 3,665 1,265 53% Mohave 67 100 33 49% Navajo 32 40 8 25% Pima 731 967 236 32% Pinal 70 110 40 57% Santa Cruz 9 12 3 33% Yavapai 106 150 44 42% Yuma 43 63 20 47% Arizona Total 3,618 5,309 1,691 47% Urban Counties 3,131 4,632 1,501 48% Rural-Urban Counties 113 154 41 36% Rural-Rural Counties 374 523 149 40% Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. Table 7.2. Pharmacists per 100,000 Population: Arizona County Changes between 2002-2007 County 2002 2003 2004 2005 2006 2007 Apache 13 12 10 10 12 11 Cochise 35 36 36 37 39 42 Coconino 58 61 62 63 69 71 Gila 51 55 57 61 60 62 Graham 36 40 40 43 42 46 Greenlee 0 0 0 0 0 0 La Paz 5 5 5 5 5 5 Maricopa 73 77 81 85 90 94 Mohave 41 39 43 45 49 51 Navajo 32 34 32 35 36 36 Pima 83 85 87 92 96 100 Pinal 35 38 37 39 38 37 Santa Cruz 23 23 22 27 26 28 Yavapai 59 62 64 68 71 71 Yuma 26 27 30 31 31 33 Arizona Total 66 70 73 77 81 84 Urban Counties 75 79 82 87 91 96 Rural-Urban Counties 39 41 43 44 46 48 Rural-Rural Counties 38 40 40 43 44 45 Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. Population estimates provided by the U.S. Census Bureau. 7-5

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 154 215 61 40% Small Rural Town 90 112 22 24% Isolated Small Rural Town 20 25 5 25% Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. Table 7.4. Pharmacists per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2002 and 2007 RUCA 2002 2003 2004 2005 2006 2007 Arizona Total 67 70 73 77 82 86 Urban 73 77 80 85 90 94 Large Rural Town 40 41 42 44 46 50 Small Rural Town 25 25 25 27 29 29 Isolated Small Rural Town 20 20 20 22 23 23 Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007. 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 2007 2004 to 2007 Apache 14 27 13 93% Cochise 46 96 50 109% Coconino 41 85 44 107% Gila 16 43 27 169% Graham 21 36 15 71% Greenlee 0 1 1 NA La Paz 4 5 1 25% Maricopa 2,292 4,758 2,466 108% Mohave 71 143 72 101% Navajo 26 51 25 96% Pima 533 973 440 83% Pinal 173 391 218 126% Santa Cruz 10 22 12 120% Yavapai 88 172 84 95% Yuma 40 102 62 155% Arizona Total 3,375 6,905 3,530 105% Urban Counties 2,825 5,731 2,906 103% Rural-Urban Counties 81 187 106 131% Rural-Rural Counties 469 987 518 110% Sources: Arizona State Board of Pharmacy, Pharmacy Technician Files 2004-2007. 7-6

Table 7.6. Pharmacy Technicians per 100,000 Population: Arizona County Changes between 2004-2007 County 2004 2005 2006 2007 Apache 21 22 33 39 Cochise 37 45 65 75 Coconino 33 44 59 67 Gila 31 49 70 83 Graham 64 85 96 104 Greenlee 0 0 13 13 La Paz 20 25 20 25 Maricopa 65 84 112 123 Mohave 40 46 60 73 Navajo 25 36 38 46 Pima 59 75 91 101 Pinal 79 95 129 131 Santa Cruz 25 32 45 51 Yavapai 46 56 71 81 Yuma 23 30 48 54 Arizona Total 59 75 99 109 Urban Counties 64 82 108 118 Rural-Urban Counties 27 36 52 59 Rural-Rural Counties 45 56 75 84 Sources: Arizona State Board of Pharmacy, Pharmacy Technician Files 2004-2007. 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 3,530 105% Urban 3,080 6,298 3,218 104% Large Rural Town 178 374 196 110% Small Rural Town 102 204 102 100% Isolated Small Rural Town 15 29 14 93% Sources: Arizona State Board of Pharmacy, Pharmacy Technician Files 2004-2007. Table 7.8. Pharmacy Technicians per 100,000 Population: Arizona s Four Rural-Urban Commuting Areas (RUCA) Changes between 2004 and 2007 RUCA 2004 2005 2006 2007 Arizona Total 59 76 101 111 Urban 63 82 109 119 Large Rural Town 44 55 73 86 Small Rural Town 28 35 45 53 Isolated Small Rural Town 15 20 26 27 Sources: Arizona State Board of Pharmacy, Pharmacy Technician Files 2004-2007. Population estimates provided by Nielsen-Claritas. 7-7

LEFT BLANK

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 2004. 1 Arizona s 38.1 EMTs per 100,000 population was less than the U.S. average of 65.1 per 100,000. 1 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: 2002-2006 Figure 8.2. Emergency Medical Technicians per 100,000 Population Profile for Arizona and Urban/Rural- Urban/Rural-Rural Counties: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. Population estimates provided by U.S. Census Bureau. 8-1

Figure 8.3. Emergency Medical Technician Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 8.4. Emergency Medical Technicians per 100,000 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. 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 2006. 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 2006. The state wide EMT-population ratios increased from 220 per 100,000 in 2002 to 244 per 100,000 in 2006. 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. 1-159. 8-2

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 2006 2002 to 2006 Apache 109 114 5 5% Cochise 397 443 46 12% Coconino 600 696 96 16% Gila 247 265 18 7% Graham 81 84 3 4% Greenlee 28 30 2 7% La Paz 53 55 2 4% Maricopa 6,059 7,766 1,707 28% Mohave 550 622 72 13% Navajo 267 326 59 22% Pima 2,068 2,593 525 25% Pinal 378 630 252 67% Santa Cruz 127 154 27 21% Yavapai 668 799 131 20% Yuma 351 455 104 30% Arizona Total 11,983 15,032 3,049 25% Urban Counties 8,127 10,359 2,232 27% Rural-Urban Counties 951 1,151 200 21% Rural-Rural Counties 2,905 3,522 617 21% Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. Table 8.2. Emergency Medical Technicians per 100,000 Population: Arizona County Changes between 2002-2006 County 2002 2003 2004 2005 2006 Apache 162 156 150 161 164 Cochise 331 317 317 306 349 Coconino 498 488 503 513 552 Gila 483 543 561 539 515 Graham 245 244 255 250 252 Greenlee 363 365 355 342 402 La Paz 274 251 249 271 275 Maricopa 184 186 192 199 206 Mohave 333 326 304 313 325 Navajo 263 265 257 264 299 Pima 236 240 241 251 273 Pinal 192 198 210 217 235 Santa Cruz 323 291 306 350 366 Yavapai 374 380 369 371 386 Yuma 211 212 236 239 245 Arizona Total 220 222 226 232 244 Urban Counties 195 197 202 209 219 Rural-Urban Counties 332 327 346 351 369 Rural-Rural Counties 296 296 293 296 313 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. Population estimates provided by the U.S. Census Bureau. 8-3

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 1,349 161 14% Small Rural Towns 967 1,084 117 12% Isolated Small Rural Towns 363 404 41 11% Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. Table 8.4. Emergency Medical Technicians per 100,000 Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2006 RUCA 2002 2003 2004 2005 2006 Arizona Total 220 221 226 235 249 Urban 206 208 215 225 237 Large Rural Towns 309 309 310 298 318 Small Rural towns 270 260 251 266 285 Isolated Small Rural Towns 361 340 343 336 383 Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. Population estimates provided by Claritas. 8-4

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 2002-2006 and on numbers in 2006. 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 2006. The two urban counties, Maricopa and Pima, accounted for 76.5 percent of the state s population in 2006. 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 2006. 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

LEFT BLANK

SECTION 10: APPENDICES Appendix A. List of Tables 1. Introduction Table 1.1 2000 and 2004 State Health Workforce Profile Publications: Arizona 1-2 Health Workforce Changes Table 1.2 Arizona Health Workforce Profile for Selected Professionals: 2006 1-2 3. Physicians Table 3.1 Total Physicians (MDs and DOs): Arizona County Changes between 3-13 2002 and 2006 Table 3.2 Total Physicians (MDs and DOs) per 100,000 Population: Arizona 3-13 County Changes between 2002-2006 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 2002-2007 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 2006 10-1

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 100,000 3-23 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 2006. 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 2006 10-2

Table 3.31 Psychiatric Physicians (MD and DO): Arizona County Changes between 3-25 2002 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 3-26 2008 by Arizona County Classification of Ruralness Table 3.36 Direct, Primary Care Physician Coverage per 100,000 Population in 3-26 2008 by Zip Code based Arizona Rural Urban Commuting Areas Classification 4. Physician Assistants Table 4.1 Physicians Assistants: Arizona County Changes between 2002 and 2007 4-3 Table 4.2 Physician Assistants per 100,000 Population: Arizona County Changes 4-3 between 2002-2007 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 2007 5. Nurses Table 5.1 Registered Nurses (RNs): Arizona County Changes between 2002 5-9 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 2007 5-10 Table 5.6 Certified Registered Nurse Anesthetist (CRNAs) per 100,000 5-11 Population: Arizona County Changes between 2002 and 2007 10-3

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 100,000 5-11 Population: Arizona s Four Rural Urban Commuting Areas (RUCA) Changes between 2002 and 2007 Table 5.9 Nurse Practitioners (NPs): Arizona County Changes between 2002 5-12 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 5-15 2002 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 5-16 2002 and 2007 Table 5.22 Certified Nurse Assistants (CNAs) per 100,000 Population: Arizona 5-17 County Changes Between 2002 and 2007 10-4

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 2007 6. Dentists Table 6.1 Number of Office Locations per Dentist in Arizona: 2002-2006 6-6 Table 6.2 Total Dentists: Arizona County Changes between 2002 and 2006 6-6 Table 6.3 Total Dentists per 100,000 Population: Arizona County Changes 6-7 between 2002-2006 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 2006 6-8 Table 6.7 General Dentists per 100,000 Population: Arizona County Changes 6-8 between 2002-2006 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 2006 6-9 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 2006 7. Pharmacists and Pharmacy Technicians Table 7.1 Pharmacists: Arizona County Changes between 2002 and 2007 7-5 Table 7.2 Pharmacists per 100,000 Population: Arizona County Changes 7-5 between 2002-2007 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 2007 10-5

Table 7.5 Pharmacy Technicians: Arizona County Changes between 2004 7-6 and 2007 Table 7.6 Pharmacy Technicians per 100,000 Population: Arizona County 7-7 Changes between 2004-2007 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 2007 8. 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 2002-2006 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 10-19 Classifications Table D.2 Estimated Cover per 100,000 population of Healthcare Workforce 10-24 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 10-19 Changes: 2002-2006 Table E.2 Arizona, Counties, and RUCAs Health Professional.Population Ratios: 2006 10-24 10-6

Appendix B. List of Figures 2. Arizona Characteristics Figure 2.1 Age Group Distribution for U.S. and Arizona: 2006 2-2 Figure 2.2 Age Group Distribution for Arizona: 2000 and 2006 2-2 Figure 2.3 Race/Ethnicity Distribution for U.S. and Arizona: 2006 2-3 Percent of Population Figure 2.4 Race/Ethnicity Distribution for Arizona: 2000 and 2006 2-3 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: 2002-2006 Figure 3.2 Total Physicians (MDs and DOs) per 100,000 Population Profile for 3-1 Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006. Figure 3.3 Total Physician (MD and DO) Profile for Arizona s Four 3-2 Rural Urban Commuting Areas: 2002-2006 Figure 3.4 Total Physicians (MDs and DOs) per 100,000 Population Profile for 3-2 Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 3.5 Total Allopathic Physician (MD) Profile for Arizona and 3-3 Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 3.6 Total Allopathic Physicians (MDs) per 100,000 Population Profile for 3-3 Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 3.7 Total Allopathic Physician (MD) Profile for Arizona s Four Rural 3-3 Urban Commuting Areas: 2002-2007 Figure 3.8 Total Allopathic Physicians (MDs) per 100,000 Population Profile for 3-3 Arizona s Four Rural Urban Commuting Areas: 2002-2007 Figure 3.9 Total Osteopathic Physician (DO) Profile for Arizona and 3-4 Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.10 Total Osteopathic Physicians (DOs) per 100,000 Population Profile for 3-4 Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.11 Total Osteopathic Physician (DO) Profile for Arizona s Four 3-4 Rural Urban Commuting Areas: 2002-2006 Figure 3.12 Total Osteopathic Physicians (DOs) per 100,000 Population Profile 3-4 for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 3.13 Total Primary Care Physician (MD and DO) Profile for Arizona and 3-5 and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 10-7

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: 2002-2006 Figure 3.15 Allopathic Primary Care Physician (MD) Profile for Arizona 3-5 and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007. Figure 3.16 Osteopathic Primary Care Physician (DO) Profile for Arizona 3-5 and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.17 Total Primary Care Physician (MD and DO) Profile for Arizona s 3-6 Four Rural Urban Commuting Areas: 2002-2006 Figure 3.18 Total Primary Care Physicians (MDs and DOs) per 100,000 3-6 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 3.19 Total Specialist Physician (MD and DO) Profile for Arizona and 3-7 Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 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: 2002-2006 Figure 3.21 Allopathic Specialist Physician (MD) Profile for Arizona and 3-8 Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 3.22 Osteopathic Specialist Physician (DO) Profile for Arizona and 3-8 Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.23 Total Specialist Physician (MD and DO) Profile for Arizona s 3-8 Four Rural Urban Commuting Areas: 2002-2006 Figure 3.24 Total Specialist Physicians (MDs and DOs) per 100,000 3-8 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2006 Figure 3.25 Total Obstetrics/Gynecology Physician (MD and DO) Profile 3-9 for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.26 Total Obstetrics/Gynecology Physicians (MDs and DOs) per 100,000 3-9 Women of Child Bearing (15-44 Year Old) Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.27 Allopathic (MD) Obstetrics/Gynecology Physician Profile for 3-9 Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 3.28 Osteopathic (DO) Obstetrics/Gynecology Physician Profile for 3-9 Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.29 Total Obstetrics/Gynecology Physician (MD and DO) Profile 3-10 for Arizona s Four Rural Urban Commuting Areas: 2002-2006 10-8

Figure 3.30 Total Obstetrics/Gynecology Physicians (MDs and DOs) per 3-10 100,000 Women of Child Bearing (15-44 Year Old) Profile for Arizona Four Rural Urban Commuting Areas: 2002-2006 Figure 3.31 Psychiatric Physician (MD and DO) Profile for Arizona and 3-10 Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.32 Psychiatric Physicians (MDs and DOs) per 100,000 Population 3-10 Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 3.33 Psychiatric Physician (MD and DO) Profile for Arizona s 3-11 Four Rural Urban Commuting Areas: 2002-2006 Figure 3.34 Psychiatric Physicians (MDs and DOs) per 100,000 Population 3-11 Profile for Arizona Four Rural Urban Commuting Areas: 2002-2006 4. Physician Assistants Figure 4.1 Physician Assistant Profile for Arizona and Urban/ 4-1 Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 4.2 Physician Assistants per 100,000 Population Profile for Arizona 4-1 and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 4.3 Physician Assistant Profile for Arizona s Four Rural 4-2 Urban Commuting Areas: 2002-2007 Figure 4.4 Physician Assistants per 100,000 Population Profile for 4-2 Arizona s Four Rural Urban Commuting Areas: 2002-2007 5. Nurses Figure 5.1 Registered Nurse (RN) Profile for Arizona and 5-1 Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.2 Registered Nurses (RNs) per 100,000 Population Profile for 5-1 Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.3 Registered Nurse (RN) Profile for Arizona s Four Rural 5-2 Urban Commuting Areas: 2002-2007 Figure 5.4 Registered Nurses (RNs) per 100,000 Population Profile for 5-2 Arizona s Four Rural Urban Commuting Areas: 2002-2007 Figure 5.5 Certified Registered Nurse Anesthetist (CRNA) Profile for Arizona 5-2 and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.6 Certified Registered Nurse Anesthetists (CRNAs) per 100,000 5-2 Population Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 10-9

Figure 5.7 Certified Registered Nurse Anesthetist (CRNA) Profile for 5-3 Arizona s Four Rural Urban Commuting Areas: 2002-2007 Figure 5.8 Certified Registered Nurse Anesthetists (CRNAs) per 100,000 5-3 Population Profile for Arizona s Four Rural Urban Commuting Areas: 2002-2007 Figure 5.9 Nurse Practitioner (NP) Profile for Arizona and 5-3 Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.10 Nurse Practitioners (NPs) per 100,000 Population Profile for 5-3 Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.11 Nurse Practitioner (NP) Profile for Arizona s Four Rural 5-4 Urban Commuting Areas: 2002-2007 Figure 5.12 Nurse Practitioners (NPs) per 100,000 Population Profile for 5-4 Arizona s Four Rural Urban Commuting Areas: 2002-2007 Figure 5.13 Certified Nurse Midwife (CNM) Profile for Arizona and 5-5 Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 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: 2002-2007 Figure 5.15 Certified Nurse Midwife (CNM) Profile for Arizona s 5-5 Four Rural Urban Commuting Areas: 2002-2007 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: 2002-2007 Figure 5.17 Licensed Practical Nurse (LPN) Profile for Arizona and 5-6 Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.18 Licensed Practical Nurses (LPNs) per 100,000 Population Profile for 5-6 Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.19 Licensed Practical Nurse (LPN) Profile for Arizona s Four Rural 5-6 Urban Commuting Areas: 2002-2007 Figure 5.20 Licensed Practical Nurses (LPNs) per 100,000 Population Profile for 5-6 Arizona s Four Rural Urban Commuting Areas: 2002-2007 Figure 5.21 Certified Nurse Assistant (CNA) Profile for Arizona and 5-7 Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.22 Certified Nurse Assistants (CNAs) per 100,000 Population Profile 5-7 for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 5.23 Certified Nurse Assistant (CNA) Profile for Arizona s Four Rural 5-7 Urban Commuting Areas: 2002-2007 10-10

Figure 5.24 Certified Nurse Assistants (CNAs) per 100,000 Population Profile for 5-7 Arizona s Four Rural Urban Commuting Areas: 2002-2007 6. Dentists Figure 6.1 Total Dentist Profile for Arizona and Urban/Rural-Urban/ 6-1 Rural-Rural Counties: 2002-2006 Figure 6.2 Total Dentists per 100,000 Population Profile for Arizona and 6-1 Urban/Rural-Urban/Rural-Rural Counties: 2002-2006. Figure 6.3 Total Dentist Profile for Arizona s Four Rural Urban Commuting 6-2 Areas: 2002-2006 Figure 6.4 Total Dentists per 100,000 Population Profile for Arizona s 6-2 Four Rural Urban Commuting Areas: 2002-2006 Figure 6.5 General Dentist Profile for Arizona and Urban/Rural-Urban/ 6-2 Rural-Rural Counties: 2002-2006 Figure 6.6 General Dentists per 100,000 Population Profile for Arizona and 6-2 Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 6.7 General Dentist Profile for Arizona s Four Rural Urban 6-3 Commuting Areas: 2002-2006 Figure 6.8 General Dentists per 100,000 Population Profile for Arizona s 6-3 Four Rural Urban Commuting Areas: 2002-2006 Figure 6.9 Specialist Dentist Profile for Arizona and Urban/Rural-Urban/ 6-3 Rural-Rural Counties: 2002-2006 Figure 6.10 Specialist Dentists per 100,000 Population Profile for Arizona 6-3 and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 6.11 Specialist Dentist Profile for Arizona s Four Rural Urban 6-4 Commuting Areas: 2002-2006 Figure 6.12 Specialist Dentists per 100,000 Population Profile for Arizona s 6-4 Four Rural Urban Commuting Areas: 2002-2006 7. Pharmacists and Pharmacy Technicians Figure 7.1 Pharmacist Profile for Arizona and Urban/Rural-Urban/ 7-1 Rural-Rural Counties: 2002-2007 Figure 7.2 Pharmacists per 100,000 Population Profile for Arizona and 7-1 Urban/Rural-Urban/Rural-Rural Counties: 2002-2007 Figure 7.3 Pharmacist Profile for Arizona s Four Rural Urban Commuting 7-2 Areas: 2002-2007 Figure 7.4 Pharmacists per 100,000 Population Profile for Arizona s Four 7-2 Rural Urban Commuting Areas: 2002-2007 10-11

Figure 7.5 Pharmacy Technician Profile for Arizona and Urban/Rural- 7-3 Urban/Rural-Rural Counties: 2004-2007 Figure 7.6 Pharmacy Technicians per 100,000 Population Profile for 7-3 Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2004-2007 Figure 7.7 Pharmacy Technician Profile for Arizona s Four Rural Urban 7-3 Commuting Areas: 2004-2007 Figure 7.8 Pharmacy Technicians per 100,000 Population Profile for 7-3 Arizona s Four Rural Urban Commuting Areas: 2004-2007 8. Emergency Medical Technicians Figure 8.1 Emergency Medical Technician Profile for Arizona and 8-1 Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 8.2 Emergency Medical Technicians per 100,000 Population 8-1 Profile for Arizona and Urban/Rural-Urban/Rural-Rural Counties: 2002-2006 Figure 8.3 Emergency Medical Technician Profile for Arizona s 8-2 Four Rural Urban Commuting Areas: 2002-2006 Figure 8.4 Emergency Medical Technicians per 100,000 Population 8-2 Profile for Arizona Four Rural Urban Commuting Areas: 2002-2006 10-12

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 2-5 3. Physicians Map 3.1 Physicians/Population Ratios by Arizona Counties for 2006 3-1 Map 3.2 Allopathic Physicians/Population Ratios by Arizona Counties for 2006 3-2 Map 3.3 Osteopathic Physicians/Population Ratios by Arizona Counties for 2006 3-3 Map 3.4 Primary Care Physicians/Population Ratios by Arizona Counties for 2006 3-5 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 2006 3-7 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 2006 3-10 4. Physician Assistants Map 4.1 Physician Assistants/Population Ratios by Arizona Counties for 2007 4-1 5. Nurses Map 5.1 Registered Nurses/Population Ratios by Arizona Counties for 2007 5-1 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 2007 5-4 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 2007 5-6 10-13

Map 5.6 Certified Nurse Assistants/Population Ratios by Arizona Counties for 2007 5-7 6. Dentists Map 6.1 Dentists/Population Ratios by Arizona Counties for 2006 6-1 Map 6.2 General Dentists/Population Ratios by Arizona Counties for 2006 6-3 Map 6.3 Specialist Dentists/Population Ratios by Arizona Counties for 2006 6-4 Map 6.4 Arizona Dental HPSA Designation: April 2009 6-5 7. Pharmacists and Pharmacy Technicians Map 7.1 Pharmacists/Population Ratios by Arizona Counties for 2007 7-1 Map 7.2 Pharmacy Technicians/Population Ratios by Arizona Counties for 2007 7-2 8. 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 10-15 Map D.2 Ruralness Base on County Classifications in Arizona 10-16 Map D.3 Ruralness by Rural Urban Commuting Areas that Are Based 10-16 on Zip Code Geography in Arizona 10-14

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 2008. 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 2008. Arizona State Board of Dental Examiners of current dentists as of September 2008. Arizona State Board of Pharmacy of past and current pharmacists and pharmacist technicians as of May 2009. 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 (http://depts.washington.edu/ruca/). 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. 10-15

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 2005-2007 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 (http://depts.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- 10-16

reporting and provide incomplete information regarding the amount and location of work conducted by each profession. Having an active license in a particular state does not necessarily mean that the person is actively working, or working in the state that they are licensed due to multiple state licenses and reciprocal agreements between states. Also, the study avoided double counting individuals with multiple different licenses and specialties by aggregating multiple records for an individual by their license numbers, name and address, and reporting them based on their most likely, active profession. For example, the nurse licensing boards report separately each type of license a person may have. Some registered nurses (RNs) have active listings as licensed practical nurses (LPNs) or advanced practice nurses (APNs). The Arizona State Board of Nursing licenses and reports those licensed RNs with additional training as a group called advance practice nurses. APNs include clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), certified nurse midwives (CNMs), school nurses (SNs), and nurse practitioners (NPs). Nurse practitioners include nine sub-specialties, each reported separately. Reporting the number of actively licensed RNs as the number of RNs in the workforce is misleading since this number will also include the licensed APNs who will most likely be working as APNs. Healthcare professionals were assigned the year or years of practice if they had a valid, active licensed on 31 December of the respective year. There were numerous missing records of individual professionals in the Arizona Department of Health Services datasets from 2000 to 2006, possibly due to late license renewals. Individuals with missing years between reported years were imputed as active during the missing years. This produced smoother trends and provided a better estimate of reality. Multiple datasets were combined using license numbers, names, and addresses of professionals. Physicians: The datasets for allopathic (MD) and osteopathic (DO) physicians from the Arizona Department of Health Services (ADHS) from 2000 to 2006 were combined with Arizona Medical Board data that was acquired February 2008. The more recent data was used to impute allopathic physicians or information about them that was missing in the ADHS dataset. The classifications of practice type were based on the first of three possible self-identified type of practice that was reported to the licensing board by each physician. The predominate type of practice that was reported for each physician between 2000 and 2008 was used to classify them as primarycare or specialty-care. The main document classifies and reports obstetrics/gynecology and psychiatry as specialty-care. The data sets included multiple records of the same physician due to separate record documentation of late or expired licensing renewals and for board disciplinary decisions. The multiple records were removed. Physician Assistants: The datasets for physician assistants from the Arizona Department of Health Services (ADHS) included only data from 2000 to 2005; unlike the other provider datasets, 2006 was not included. The Arizona Medical Board data that was acquired February 2008 included data on physician assistants. This data was used to impute the number of physician assistants for 2006 and 2007. Nurses: The Arizona Department of Health Services (ADHS) datasets of currently licensed nurses from 2000 to 2006 were combined with Arizona State Board of Nursing data on current and past nurses as of October 2008. Advance practice registered nurses in the datasets were identified as acute care nurse practitioners, adult nurse practitioners, family nurse practitioners, gerontological nurse practitioners, neonatal nurse practitioners, pediatric nurse practitioners, psychiatric nurse practitioners, mental health nurse practitioners, women s health nurse practitioners, certified nurse midwives, clinical nurse specialists, certified registered nurse anesthetists, and school nurses. We reported and analyzed certified nurse midwives, clinical nurse specialists, certified registered nurse anesthetists separately, school nurses were grouped with registered nurses, and all other advance practice registered nurses were grouped as nurse practitioners. Registered nurses, licensed practical nurses, and certified nursing assistants were reported and analyzed separately. The 2001 ADHS registered nurse data was missing and was imputed from data of subsequent years. The 2003 ADHS nurse practitioner data set included a large number of license practical nurses that were identified by license numbers. The datasets of all nurse types were combined based on multiple levels of licensure, their license numbers, names, and location to avoid double counting. The highest level of licensure was reported; for example, all nurse practitioners are also registered nurses but in this reporting and analysis they were not included with registered nurses to avoid double counting. The predominate type of advanced practice specialty that 10-17

was reported for each advanced practice registered nurse between 2000 and 2008 was used to classify each advanced practice nurse. Dentists: The datasets for dentists from Arizona Department of Health Services (ADHS) from 2000 to 2006 provided all the locations of practice reported by each dentist and had a pseudo Full-Time-Equivalent (FTE) value assigned that 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 then each location was assigned 0.5 FTE, in three locations then 0.33 FTE was assigned, etc. The workforce counts and relative counts are reported by these pseudo-ftes. If dentists reported a specialty then they were classified as a specialist; the others were classified as primary care. Pharmacists: The Arizona State Board of Pharmacy provided an historic dataset on May 2009 that included data on pharmacists that were licensed in Arizona from 1931 to 2009. The latest reported practice location was imputed for previous years that they had active licenses in Arizona. Pharmacist Technicians: Data from the Arizona State Board of Pharmacy included data on pharmacist technicians that were licensed from 2004 to 2009. Estimated count for years prior to 2004 was not included due to the unknown number of technicians who stopped practicing and would result in underestimates of the workforce prior to 2004. Emergency Medical Technicians: The datasets for emergency medical technicians (EMTs) from the Arizona Department of Health Services (ADHS) from 2000 to 2006 did not include names and certification numbers were only provided for 2003 and 2004 data that might have allowed identification and reporting of missing EMTs. Imputation was done for missing county and zip code data as explained above. D.3 Comparing Workforce Estimates Care needs to be exercised when comparing estimates of workforce coverage from different studies (Table D.2) 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. A more important question than how workforce coverage compares to other areas is is the population receiving good healthcare. Analysis of trends in the number of healthcare professionals relative to the population they serve give a good estimate if the health care is improving or not. The analysis of numbers of healthcare professionals provides an indication of the number of recruited professionals that are needed to produce noticeable change. 10-18

Table D.1. List of Town and Cities in Arizona and their Ruralness Classification Town-City County County Ruralness Zip Code-RUCA Ajo Pima Urban Small rural town Ak-Chin Village Pinal Rural Urban Amado Santa Cruz Rural Urban Apache Junction Pinal Rural Urban Arizona City Pinal Rural Small rural town Arizona Village Mohave Rural Small rural town Ash Fork Yavapai Rural Isolated small rural town Avondale Maricopa Urban Urban Avra Valley Pima Urban Urban Bagdad Yavapai Rural Isolated small rural town Benson Cochise Rural Small rural town Big Park Yavapai Rural Small rural town Bisbee Cochise Rural Small rural town Bitter Springs Coconino Rural-Urban Small rural town Black Canyon City Yavapai Rural Urban Blackwater Pinal Rural Isolated small rural town Bluewater La Paz Rural Small rural town Bouse La Paz Rural Small rural town Buckeye Maricopa Urban Urban Bullhead City Mohave Rural Small rural town Burnside Apache Rural Small rural town Cameron Coconino Rural-Urban Small rural town Camp Verde Yavapai Rural Isolated small rural town Canyon Day Gila Rural Small rural town Carefree Maricopa Urban Urban Casa Grande Pinal Rural Large rural town Casas Adobes Pima Urban Urban Catalina Pima Urban Urban Catalina Foothills Pima Urban Urban Cave Creek Maricopa Urban Urban Chandler Maricopa Urban Urban Chilchinbito Navajo Rural Small rural town Chinle Apache Rural Small rural town Chino Valley Yavapai Rural Urban Chuichu Pinal Rural Large rural town Cibecue Navajo Rural Small rural town Cibola La Paz Rural Urban Cienega Springs La Paz Rural Small rural town Clarkdale Yavapai Rural Large rural town Claypool Gila Rural Large rural town Clifton Greenlee Rural Small rural town Colorado City Mohave Rural Small rural town Congress Yavapai Rural Urban Coolidge Pinal Rural Small rural town Cordes Lakes Yavapai Rural Urban 10-19

Town-City County County Ruralness Zip Code-RUCA Cornville Yavapai Rural Small rural town Corona de Tucson Pima Urban Urban Cottonwood Yavapai Rural Large rural town Dennehotso Apache Rural Small rural town Desert Hills Mohave Rural Large rural town Dewey-Humbolt Yavapai Rural Urban Dilkon Navajo Rural Small rural town Dolan Springs Mohave Rural Large rural town Douglas Cochise Rural Large rural town Drexel Heights Pima Urban Urban Dudleyville Pinal Rural Isolated small rural town Duncan Greenlee Rural Isolated small rural town Eagar Apache Rural Small rural town East Fork Navajo Rural Small rural town East Sahuarita Pima Urban Urban Ehrenberg La Paz Rural Large rural town El Mirage Maricopa Urban Urban Elgin Santa Cruz Rural Isolated small rural town Eloy Pinal Rural Small rural town First Mesa Navajo Rural Isolated small rural town Flagstaff Coconino Rural-Urban Urban Florence Pinal Rural Large rural town Flowing Wells Pima Urban Urban Fort Defiance Apache Rural Small rural town Fortuna Foothills Yuma Rural-Urban Urban Fountain Hills Maricopa Urban Urban Fredonia Coconino Rural-Urban Isolated small rural town Gadsden Yuma Rural-Urban Urban Ganado Apache Rural Small rural town Gila Bend Maricopa Urban Urban Gilbert Maricopa Urban Urban Gisela Gila Rural Large rural town Glendale Maricopa Urban Urban Globe Gila Rural Large rural town Gold Canyon Pinal Rural Urban Golden Valley Mohave Rural Large rural town Goodyear Maricopa Urban Urban Grand Canyon Village Coconino Rural-Urban Isolated small rural town Greasewood Navajo Rural Small rural town Green Valley Pima Urban Urban Guadalupe Maricopa Urban Urban Hayden Gila Rural Isolated small rural town Holbrook Navajo Rural Small rural town Hotevilla-Bacavi Navajo Rural Isolated small rural town Houck Apache Rural Small rural town Huachuca City Cochise Rural Large rural town 10-20

Town-City County County Ruralness Zip Code-RUCA Jeddito Navajo Rural Isolated small rural town Jerome Yavapai Rural Large rural town Kachina Village Coconino Rural-Urban Urban Kaibab Mohave Rural Small rural town Kaibito Coconino Rural-Urban Small rural town Kayenta Navajo Rural Small rural town Keams Canyon Navajo Rural Isolated small rural town Kearny Pinal Rural Isolated small rural town Kingman Mohave Rural Large rural town Kykotsmovi Village Navajo Rural Isolated small rural town Lake Havasu City Mohave Rural Large rural town Lake Montezuma Yavapai Rural Isolated small rural town LeChee Coconino Rural-Urban Small rural town Leupp Coconino Rural-Urban Urban Litchfield Park Maricopa Urban Urban Littletown Pima Urban Urban Lukachukai Apache Rural Isolated small rural town Mammoth Pinal Rural Urban Many Farms Apache Rural Small rural town Marana Pima Urban Urban Maricopa Pinal Rural Urban Mayer Yavapai Rural Urban McNary Apache Rural Small rural town Mesa Maricopa Urban Urban Mesquite Creek Mohave Rural Small rural town Miami Gila Rural Large rural town Moenkopi Coconino Rural-Urban Small rural town Mohave Valley Mohave Rural Small rural town Mojave Ranch Estates Mohave Rural Small rural town Morenci Greenlee Rural Small rural town Mountainaire Coconino Rural-Urban Urban Munds Park Coconino Rural-Urban Small rural town Naco Cochise Rural Small rural town Nazlini Apache Rural Small rural town New River Maricopa Urban Urban Nogales Santa Cruz Rural Large rural town Oracle Pinal Rural Urban Oro Valley Pima Urban Urban Page Coconino Rural-Urban Small rural town Paradise Valley Maricopa Urban Urban Parker La Paz Rural Small rural town Parks Coconino Rural-Urban Isolated small rural town Patagonia Santa Cruz Rural Isolated small rural town Paulden Yavapai Rural Urban Payson Gila Rural Large rural town Peach Springs Mohave Rural Large rural town 10-21

Town-City County County Ruralness Zip Code-RUCA Peeples Valley Yavapai Rural Urban Peoria Maricopa Urban Urban Peridot Gila Rural Small rural town Phoenix Maricopa Urban Urban Picture Rocks Pima Urban Urban Pima Graham Rural Large rural town Pine Gila Rural Large rural town Pinetop-Lakeside Navajo Rural Small rural town Pinon Navajo Rural Isolated small rural town Pirtleville Cochise Rural Large rural town Pisinemo Pima Urban Isolated small rural town Poston La Paz Rural Small rural town Prescott Yavapai Rural Urban Prescott Valley Yavapai Rural Urban Quartzsite La Paz Rural Small rural town Queen Creek Maricopa Urban Urban Queen Valley Pinal Rural Urban Red Mesa Apache Rural Isolated small rural town Rio Verde Maricopa Urban Urban Rock Point Apache Rural Isolated small rural town Rough Rock Apache Rural Small rural town Round Rock Apache Rural Small rural town Sacaton Pinal Rural Isolated small rural town Safford Graham Rural Large rural town Sahuarita Pima Urban Urban Salome La Paz Rural Isolated small rural town San Carlos Gila Rural Small rural town San Luis Yuma Rural-Urban Urban San Luis Pima Urban Isolated small rural town San Manuel Pinal Rural Small rural town Santa Rosa Pima Urban Isolated small rural town Sawmill Apache Rural Small rural town Scottsdale Maricopa Urban Urban Second Mesa Navajo Rural Isolated small rural town Sedona Coconino Rural-Urban Small rural town Seligman Yavapai Rural Isolated small rural town Sells Pima Urban Isolated small rural town Shonto Navajo Rural Small rural town Show Low Navajo Rural Small rural town Shungopavi Navajo Rural Isolated small rural town Sierra Vista Cochise Rural Large rural town Snowflake Navajo Rural Small rural town Somerton Yuma Rural-Urban Urban Sonoita Santa Cruz Rural Isolated small rural town South Tucson Pima Urban Urban Spring Valley Yavapai Rural Urban 10-22

Town-City County County Ruralness Zip Code-RUCA Springerville Apache Rural Small rural town Stanfield Pinal Rural Urban Star Valley Gila Rural Large rural town Steamboat Apache Rural Small rural town Stotonic Pinal Rural Isolated small rural town Strawberry Gila Rural Large rural town Summit Pima Urban Urban Sun City Maricopa Urban Urban Sun City West Maricopa Urban Urban Sun Lakes Maricopa Urban Urban Sun Valley Navajo Rural Small rural town Superior Pinal Rural Urban Surprise Maricopa Urban Urban Swift Trail Junction Graham Rural Large rural town Tacna Yuma Rural-Urban Urban Tanque Verde Pima Urban Urban Taylor Navajo Rural Small rural town Teec Nos Pos Apache Rural Isolated small rural town Tempe Maricopa Urban Urban Thatcher Graham Rural Large rural town Three Points Pima Urban Urban Tolleson Maricopa Urban Urban Tombstone Cochise Rural Isolated small rural town Tonalea Coconino Rural-Urban Small rural town Tonto Basin Gila Rural Large rural town Top-of-the-World Gila Rural Large rural town Tortolita Pima Urban Urban Tsaile Apache Rural Isolated small rural town Tuba City Coconino Rural-Urban Small rural town Tubac Santa Cruz Rural Isolated small rural town Tucson Pima Urban Urban Tucson Estates Pima Urban Urban Tusayan Coconino Rural-Urban Isolated small rural town Vail Pima Urban Urban Wellton Yuma Rural-Urban Urban Wenden La Paz Rural Isolated small rural town Whetstone Cochise Rural Large rural town Whiteriver Navajo Rural Small rural town Wickenburg Maricopa Urban Urban Wilhoit Yavapai Rural Urban Willcox Cochise Rural Small rural town Williams Coconino Rural-Urban Isolated small rural town Williamson Yavapai Rural Urban Willow Valley Mohave Rural Small rural town Window Rock Apache Rural Small rural town 10-23

Town-City County County Ruralness Zip Code-RUCA Winkelman Gila Rural Isolated small rural town Winslow Navajo Rural Small rural town Winslow West Coconino Rural-Urban Urban Yarnell Yavapai Rural Urban Young Gila Rural Large rural town Youngtown Maricopa Urban Urban Yuma Yuma Rural-Urban Urban Source: Rural Urban Commuting Areas (RUCA) Classification. Population estimates provided by Nielsen-Claritas Table D.2. Estimated Cover per 100,000 population of Healthcare Workforce in 2004 for Arizona and United States Arizona (RHO-AHEC)* Arizona (NYCHWS)** United States (NYCHWS)** State Rankings (NYCHWS)** Profession Physicians 222.0 191.0 214.1 35/50 Primary Care Physicians 73.7 67.6 76.6 39/50 Specialist Physicians 148.3 --- --- --- OB/GYN Physicians 64.6 --- --- --- Psychiatrist Physicians 12.4 4.2 5.2 30/40 (10 missing) Physician Assistants 19.9 9.2 7.8 10/50 Advance Practice Nurses 46.9 --- --- --- Nurse Practitioners 30.9 45.7 42.0 21/50 CRNAs 2.8 2.8 2.5 23/50 Certified Nurse Midwives @ 12.8 5.5 149.7 41/44 (6 missing) Registered Nurses 853.3 678.0 802.0 45/50 Licensed Practical Nurses 132.1 141.0 239.3 46/50 Certified Nurse Assistants 358.5 --- --- --- Dentists 50.2 51.8 59.4 22/50 General Dentists 41.6 ---- --- --- Specialist Dentists 8.6 ---- --- --- Pharmacists 72.5 66.7 77.0 46/50 Pharmacy Technicians 58.8 104.6 105.7 24/50 Emergency Med. Tech. 225.7 38.1 65.1 45/50 * Estimates from this AHEC study. ** Estimates from The United States Health Workforce Profile by the New York Center for Health Workforce Studies, 2006. @ Coverage of certified nurse midwives estimated for this study was based on population of females 15 to 44 years of age. 10-24

Appendix E. Arizona, Counties, and RUCAs Health Workforce Comparisons Table E1. Arizona, Counties, and RUCAs Health Professional Percentage Changes: 2002 to 2006 County Population Changes Physician Total Physician PC Physician Specialists Physician OB/Gyn Physician Psych Apache 3.3% -24% -23% -26% 0% 0% Cochise 5.8% 1% 7% -2% 0% -13% Coconino 4.7% 7% 10% 6% -9% 0% Gila 0.5% 4% 13% -2% -29% 0% Graham 0.8% 14% 14% 13% 100% NA Greenlee -3.1% 14% 0% 33% NA NA La Paz 3.5% 6% 10% 0% NA NA Maricopa 14.5% 18% 21% 17% 9% 10% Mohave 16.0% 28% 28% 28% 5% 22% Navajo 7.7% 8% 7% 10% -10% -60% Pima 8.1% 8% 11% 7% 1% 7% Pinal 36.0% 31% 33% 29% 38% 25% Santa Cruz 7.1% 3% -10% 23% 0% NA Yavapai 15.8% 20% 23% 19% 46% 18% Yuma 11.7% 26% 32% 22% 0% -33% Arizona 13.2% 16% 18% 15% 7% 8% Counties Urban 13.1% 16% 18% 15% 7% 9% Rural-Urban 8.8% 15% 20% 12% -6% -10% Rural-Rural 14.9% 16% 16% 16% 13% 9% RUCAs Urban Areas 11.8% 16% 19% 15% 8% 8% LRT 10.1% 14% 19% 11% 5% 22% SRT 6.3% 9% 4% 13% 3% 0% ISRT 4.8% 0% 4% -13% NA 0% 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, 2002-2006. Key: LRT Large Rural Town, SRT Small Rural Town, and ISRT Isolated Small Rural Town 10-25

Table E1. Arizona, Counties, and RUCAs Health Professional Percentage Changes: 2002 to 2006 (Cont d) Population Physician Registered Nurse CNMs LPNs Cert. Nurse County Changes Assistants Nurses Practitioners Assistants Apache 3.3% -44% 27% 50% 25% 14% -3% Cochise 5.8% 5% 8% 23% 0% 14% 14% Coconino 4.7% 18% 17% 46% 14% 17% 69% Gila 0.5% -25% 2% 30% NA 13% 13% Graham 0.8% 0% 17% 150% 0% 82% 23% Greenlee -3.1% -71% -8% NA NA 56% 27% La Paz 3.5% -33% 4% 50% NA 45% -39% Maricopa 14.5% 55% 14% 38% 11% 27% 10% Mohave 16.0% 30% 18% 52% 0% 22% 23% Navajo 7.7% 19% 12% 30% 0% 27% 25% Pima 8.1% 52% 11% 33% 8% 18% 6% Pinal 36.0% 63% 55% 180% -50% 42% 12% Santa Cruz 7.1% -50% 22% 50% NA 23% 13% Yavapai 15.8% 68% 13% 47% 33% 12% 14% Yuma 11.7% 48% 24% 50% 14% 35% 5% Arizona 13.2% 46% 15% 40% 10% 25% 11% Counties Urban 13.1% 55% 14% 37% 10% 25% 9% Rural-Urban 8.8% 31% 20% 47% 14% 28% 28% Rural-Rural 14.9% 18% 20% 57% 10% 25% 15% RUCAs Urban Areas 11.8% 55% 15% 40% 10% 26% 10% LRT 10.1% 20% 12% 45% 0% 17% 15% SRT 6.3% -7% 12% 38% 7% 25% 22% ISRT 4.8% 20% 8% 37% 100% 15% 3% 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, 2002-2006, Arizona Board of Nursing, Nurse Practitioners File 2008. Key: LRT Large Rural Town, SRT Small Rural Town, and ISRT Isolated Small Rural Town 10-26

Table E1. Arizona, Counties, and RUCAs Health Professional Percentage Changes: 2002 to 2006 Cont d) Population Dentist Dentist Dentist Pharmacists Pharmacy EMTs County Changes Total General Specialists Technicians Apache 3.3% 46% 38% 91% -11% 64% 5% Cochise 5.8% 25% 24% 32% 17% 78% 12% Coconino 4.7% 11% 3% 52% 24% 80% 16% Gila 0.5% 6% 15% -48% 19% 125% 7% Graham 0.8% 6% 6% 6% 17% 52% 4% Greenlee -3.1% -31% -31% NA NA NA 7% La Paz 3.5% 50% 25% NA 0% 0% 4% Maricopa 14.5% 31% 26% 56% 42% 84% 28% Mohave 16.0% 27% 26% 40% 40% 62% 13% Navajo 7.7% 22% 17% 46% 22% 62% 22% Pima 8.1% 19% 17% 26% 24% 62% 25% Pinal 36.0% 69% 59% 177% 46% 101% 67% Santa Cruz 7.1% 20% 20% NA 22% 90% 21% Yavapai 15.8% 29% 31% 16% 38% 66% 20% Yuma 11.7% 30% 31% 24% 35% 123% 30% Arizona 13.2% 28% 24% 48% 37% 81% 25% Counties Urban 13.1% 28% 24% 49% 38% 80% 27% Rural-Urban 8.8% 18% 13% 41% 28% 101% 21% Rural-Rural 14.9% 30% 29% 38% 32% 81% 21% RUCAs Urban Areas 11.8% 29% 25% 49% 38% 81% 29% LRT 10.1% 24% 21% 39% 27% 74% 14% SRT 6.3% 19% 18% 24% 21% 68% 12% ISRT 4.8% 6% 10% -100% 20% 80% 11% Sources: Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006, Arizona State Board of Pharmacy, Pharmacist Files 2002-2007, and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. Key: LRT Large Rural Town, SRT Small Rural Town, and ISRT Isolated Small Rural Town 10-27

Table E2. Arizona, Counties, and RUCAs Health Professional/Population Ratios: 2006 COUNTY Physician Total Physician PC Physician Specialists Physician OB/Gyn Physician Psych Physician Assistants Registered Nurses Apache 49 29 20 35 1 13 400 Cochise 116 50 65 44 6 17 696 Coconino 235 77 158 74 16 32 1,053 Gila 146 68 78 60 2 17 700 Graham 99 72 27 62 0 30 612 Greenlee 107 54 54 0 13 27 321 La Paz 90 55 35 37 0 10 290 Maricopa 233 76 157 64 12 24 837 Mohave 155 45 110 63 6 27 693 Navajo 109 59 50 41 2 17 595 Pima 289 84 205 68 19 14 997 Pinal 73 41 33 22 4 16 644 Santa Cruz 81 43 38 47 0 2 314 Yavapai 186 68 119 54 13 18 989 Yuma 135 53 82 34 3 22 546 Arizona 218 72 146 60 12 22 829 Counties Urban 244 77 167 64 13 22 869 Rural-Urban 175 63 113 52 8 26 751 Rural-Rural 120 51 68 43 5 18 682 RUCAs Urban Areas 240 76 164 63 13 22 890 LRT 150 60 90 59 5 23 694 SRT 107 51 55 47 4 20 543 ISRT 58 45 13 5 1 11 400 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, 2002-2006, 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, 2002-2006, Arizona Board of Nursing, Nurse Practitioners File 2008.. Key: LRT Large Rural Town, SRT Small Rural Town, and ISRT Isolated Small Rural Town Population estimates provided by the U.S. Census Bureau. 10-28

Table E2. Arizona, Counties, and RUCAs Health Professional/Population Ratios: 2006 (Cont d) Nurse CNMs LPNs Cert. Nurse Dentist Dentist Dentist COUNTY Practitioners Assistants Total General Specialists Apache 17 35 60 341 26 21 5 Cochise 30 4 159 405 36 29 7 Coconino 68 28 67 477 62 48 14 Gila 25 0 214 723 39 36 3 Graham 15 16 120 855 46 37 9 Greenlee 0 0 187 509 20 20 0 La Paz 15 0 80 125 15 12 2 Maricopa 34 8 137 294 60 48 12 Mohave 20 9 126 386 37 33 4 Navajo 24 32 99 399 40 32 8 Pima 48 27 185 337 53 43 10 Pinal 21 2 175 383 26 22 4 Santa Cruz 21 12 116 404 21 21 0 Yavapai 36 11 136 455 60 52 8 Yuma 18 23 91 366 28 23 5 Arizona 34 12 142 330 54 44 10 Counties Urban 36 12 147 302 59 47 11 Rural-Urban 38 25 81 411 42 33 9 Rural-Rural 24 11 140 425 37 32 5 RUCAs Urban Areas 37 13 149 324 58 47 11 LRT 24 4 157 476 39 33 6 SRT 18 21 88 352 36 30 6 ISRT 25 10 109 332 21 19 1 Sources: Arizona Board of Nursing, Nurse Practitioners File 2008, Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Dentist Statistical Files, 2002-2006, Key: LRT Large Rural Town, SRT Small Rural Town, and ISRT Isolated Small Rural Town Population estimates provided by the U.S. Census Bureau. 10-29

Table E2. Arizona, Counties, and RUCAs Health Professional/Population Ratios: 2006 (Cont d) County Pharmacists Pharmacy Technicians EMTs Number of Bottom 5 Counties Health Professions Apache 12 33 164 15/17 Cochise 39 65 349 2/17 Coconino 69 59 552 1/17 Gila 60 70 515 3/17 Graham 42 96 252 5/17 Greenlee 0 13 402 9/17 La Paz 5 20 275 15/17 Maricopa 90 112 206 2/17 Mohave 49 60 325 3/17 Navajo 36 38 299 3/17 Pima 96 91 273 2/17 Pinal 38 129 235 10/17 Santa Cruz 26 45 366 11/17 Yavapai 71 71 386 0/17 Yuma 31 48 245 7/17 Arizona 81 99 244 ----- Counties ---- Urban 91 108 219 ---- Rural-Urban 46 52 369 ---- Rural-Rural 44 75 313 ---- RUCAs ---- Urban Areas 90 109 237 ---- LRT 46 73 318 ---- SRT 29 45 285 ---- ISRT 23 26 383 ---- Sources: Arizona State Board of Pharmacy, Pharmacist Files 2002-2007, and Arizona Department of Health Services, Arizona Primary Care Area Program, Primary Care Area Emergency Medical Technician Statistical Files, 2002-2006. Key: LRT Large Rural Town, SRT Small Rural Town, and ISRT Isolated Small Rural Town Population estimates provided by the U.S. Census Bureau. 10-30

LEFT BLANK 10-31

A publication of the Arizona Area Health Education Centers Program prepared by the Arizona Rural Health Office Mel And Enid Zuckerman College of Public Health The University of Arizona 1834 E. Mabel Street Tucson, AZ 85721 (520) 626-4030 www.azahec.org