Children in Many Geographic Areas Lack Access to Primary Care Physicians

Laurie Barclay, MD

December 20, 2010

December 20, 2010 — Children in many geographic areas of the United States lack access to primary care physicians, according to the results of a study reported online December 20 in Pediatrics.

"Concerns about the sufficiency of the primary care workforce have led to efforts to train more primary care physicians," write Scott A. Shipman, MD, MPH, from Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, New Hampshire, and colleagues. "Inequitable distribution of the physician workforce, a long-standing problem, has received less attention, particularly with respect to children. This study examines growth in the primary care physician workforce for children and examines the geographic distribution of the workforce."

The investigators used US national data to assess primary care service areas in terms of local per capita supply of clinically active general pediatricians and family physicians. Although the general pediatrician workforce increased by 51% from 1996 to 2006 and the family physician workforce increased by 35% during the same period, the child population increased by only 9%. Across local primary care markets, the 2006 per capita supply varied by more than 600%.

Almost 1 million US children lived in areas with no local child physician, and about one fifth of the US child population (nearly 15 million children) lived in areas with more than 4400 children per child physician (average of 22 child physicians per 100,000 children). In contrast, another 15 million US children lived in local markets with fewer than 710 children per child physician (average of 141 child physicians per 100,000 children). Similar extremes of physician maldistribution were present in nearly all 50 states.

"Despite pronounced growth of the primary care workforce for children, millions of children live in areas with insufficient local supplies of primary care physicians," the study authors write. "More effective policies targeting adequate geographic access to primary care are needed."

Limitations of this study include the reliance on the American Medical Association Physician Masterfile, which is imprecise; the inability to account for the fact that pediatricians in high-supply areas may be more likely to practice part-time or for region-specific differences in the retirement age of physicians; and the lack of data on physician assistants and nurse practitioners. In addition, this study did not address insurance status or cultural characteristics.

"Unless expansion is targeted explicitly toward serving populations with the greatest needs, it may lead to greater health care inequities, with little improvement in the quality or outcomes of care," the study authors conclude. "Accountability for the public funds that support medical training should start with concerted, transparent efforts to develop, to use, and to evaluate policies aimed at reducing disparities in geographic access to care caused by extremes of physician maldistribution."

The Robert Wood Johnson Foundation supported this study. Dr. Shipman and Dr. Goodman also received funding from the Health Resources and Services Administration, and Dr. Goodman received support from the National Institute of Aging and from the Centers for Medicare and Medicaid Services through the Colorado Foundation for Medical Care. The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online December 20, 2010.

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