Graves John A, Mishra Pranita, Dittus Robert S, Parikh Ravi, Perloff Jennifer, Buerhaus Peter I
*Department of Health Policy, Institute for Medicine and Public Health†Health Systems Data Analyst I, Department of Health Policy‡Population Health Sciences, Institute for Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN§Department of Ophthalmology and Visual Sciences, Yale University, New Haven, CT∥Heller School for Social Policy and Management, Brandeis University, Waltham, MA¶Center for Interdisciplinary Health Workforce Studies, College of Nursing, Nashville, TN.
Med Care. 2016 Jan;54(1):81-9. doi: 10.1097/MLR.0000000000000454.
Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians--particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured.
We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws.
An observational study.
2013 Area Health Resource File (AHRF) and US Census Bureau county travel data.
The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC.
We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations.
Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains.
对于包括医生和非医生临床医生在内的基层医疗劳动力的地理分布情况，我们了解甚少——尤其是在执业范围法律限制严格的地区以及未参保人数相对较多的地区。
我们调查了基层医疗临床医生（PCC）在城乡之间以及执业范围法律限制程度不同的州之间的地理可及性是否存在差异。
一项观察性研究。
2013年地区卫生资源文件（AHRF）和美国人口普查局的县出行数据。
这些指标包括低可及性、中等可及性和高可及性地区的人口百分比；每10万人口中地理可及的基层医疗医生（PCMD）、执业护士（PCNP）和医师助理（PCPA）的数量；以及每一位PCC对应的未参保人数。
我们发现PCC的地理可及性存在不同模式。在所有环境中，PCMD在劳动力中所占份额最大，但相对更集中在城市地区。农村地区非医生的可及性最高：在执业范围受限州的农村地区，每10万人口中可及的PCNP数量（21.4）比在执业范围不受限州的城市地区（13.9）更多。尽管农村地区有更多可及的非医生临床医生，但在2012年，农村地区每一位PCC对应的未参保人数却是最多的。虽然执业范围限制较少的州在某些地区的PCNP数量多出多达40%，但我们几乎没有发现不同执业范围分类下低可及性地区总人口比例存在差异的证据。
取消执业范围限制法律可能会扩大基层医疗劳动力的总体规模，但在短期内增幅不大。还需要做出更多努力，认识到医生和非医生的分布倾向。
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