• Physician Distribution and Access: Workforce Priorities

    One Pagers | May 15, 2008
    Xingyou Zhang, PhD; Bob Phillips, MD MSPH; Andrew Bazemore, MD MPH; Martey Dodoo, PhD; Stephen Petterson, PhD; Imam Xierali, PhD, and Larry A. Green, MD

    Most Primary Care Health Professional Shortage Areas (HPSAs) exceed federal population-to-physician designation criteria, yet struggle to maintain access to primary care physicians. Policy options for recruiting and retaining primary care physicians to HPSAs, and new HPSA criteria that support access to primary care practices, should be considered. 

    Whether the United States has enough physicians is controversial, but the ongoing problem of physician distribution is certain. HPSA designation for an area or population is one means of directing resources to enhance access to care and currently requires fewer than one physician for every 3,500 people in a specific area, or one per 3,000 people for areas with poor health outcomes. 

    In 2006, nearly 75 percent of counties were designated as whole- or partial-county HPSAs. However, estimates for the physician shift needed showed that previously designated HPSAs already averaged one primary care physician per 1,661 people (see accompanying table). Even if current physician requirements were doubled to one physician per 1,500 people, the movement of 5,313 primary care physicians into HPSAs could eliminate all HPSAs.1,2 Added up, the need in each HPSA would require 13,352 physicians to move; however, 7,000 of these could be from overstaffed HPSAs to understaffed HSPAs.1,2 Non-HPSA counties could collectively lose 71,168 physicians and not fall below this ratio (one per 1,500). Although these analyses are based on the best available workforce data, they may miss or lose track of some physicians and do not account for those commuting to HPSAs or practicing part-time.

    Table. Population-to-Physician Ratios by Area Type

    Types of area No. of physicians (1) Population (2) Population-to-physician ratio Physician surplus (+) or shortage (-) of 1,500:1 ratio
    All HSPAs 49,440 82,129,981 1,661:1 -5,313
    All non-HSPAs 215,096 215,891,310 1,004:1 +71,168
    Urban HSPAs 35,578 56,559,848 1,591:1 -2,129
    Urban non-HSPAs 196,063 191,410,420 976:1 +68,456
    Rural HPSAs 13,862 25,570,133 1,845:1 -3,185
    Rural non-HSPAs 19,033 24,480,890 1286:1 +2,712

    HPSA = health professional shortage areas. 
    Information from references 1 and 2. 

    Certainly there are real areas of shortage hidden in these averages, but even if HPSA criteria were increased, solving the distribution problem would require shifting a relatively small number of physicians. However, getting physicians to serve in these areas may not be easy or inexpensive and requires specific policy and resources. A recent increase in the number of HPSAs, despite the declining average ratio, may reflect health care access problems unaffected by creating more physicians-the current focus in most states. Policy-makers should consider improvements that refocus HPSA designation and resource allocation (e.g., offering grants or loans to physicians who locate to shortage areas; reducing physician-to-population thresholds to better reflect true need; focusing more resources where the ratios are worst; finding criteria that are more reflective of access to care than physician counts). 



    1. American Medical Association. AMA Physician Masterfile; 2006.
    2. U.S. Census Bureau. Annual county population estimates and estimated components of change: April 1, 2000 to July 1, 2006. March 2007. http://www.census.gov/popest/counties/files/CO-EST2006-alldata.txt. Accessed March 19, 2008.

    The information and opinions contained in research from the Graham Center do not necessarily reflect the views or the policy of the AAFP.

    Published in American Family Physician, May15, 2008. Am Fam Physician. 2008;77(10):1378. This series is coordinated by Sumi Sexton, MD, AFP Associate Medical Editor.