Rural–Urban Health Care Provider Disparities in Alaska and New Mexico

Administration and Policy in Mental Health and Mental Health Services Research, Vol. 33, No. 4, July 2006 (Ó 2005) DOI: 10.1007/s10488-005-0001-7 Rural–Urban Health Care Provider Disparities in Alaska and New Mexico Mark E. Johnson,1,6 Christiane Brems,1 Teddy D. Warner,2,3,4 and Laura Weiss Roberts5 Compared to their urban counterparts, rural residents face numerous disparities in obtaining health care, including limited access to care providers. We assessed disparities in provider availability in rural versus urban Alaska and New Mexico, with emphasis on professionals likely to provide mental health care. Using lists of licenses, we categorized physical and mental health care providers into rural versus urban and calculated rural versus urban disparity ratios. Rural residents had significantly less access to health care providers and discrepancies grew with level of required provider education and specialization. Addressing disparities via creative strategies is crucial to improving rural care delivery. KEY WORDS: health care disparities; provider shortages; rurality; rural; urban. geographic distance and widely dispersed services to the absence of needed services in the community of residence (Bull, et al., 2001; Ciarlo & Zelarney, 2000; Mathews-Cowey, 2000; Morgan, Semchuk, Stewart, & D’Arcy, 2002). Poor financial access is related to issues of poverty on the part of the patient, as well as level and sources of funding on larger community wide scale (Fox, Blank, Rovnyak, & Barnett, 2001; Geller, Beeson, & Rodenhiser, 2000). Psychological access is related to consumer traits that interfere with or facilitate service utilization. Basic physical health and mental health care access, the focus of this article, presents a challenge for rural compared to urban residents, in part due to the existence of fewer care providers in rural and frontier areas (Holzer, Golsmith, & Ciarlo, 2000; Williams & Cutchin, 2002). Rural versus urban provider availability has been studied previously, using census areas across the United States. According to such investigations, misdistribution and rural shortages have existed for hundreds of years, despite many federal, state, and private Numerous health care disparities have been documented for rural healthcare consumers (Geyman, Hart, & Norris, 2001; Stamm, 2003). For example, rural populations face more challenges and barriers in assuring appropriate, timely, and cost-effective care (Jensen & Royseen, 2002; Mohatt, 2000; Strasser, 2003) and have less access to specialized health care (Geller & Muus, 2000; Merwin, Golsmith, & Manderscheid, 1995). Access to health care has at least three spheres, as defined by Mohatt (2000), namely, physical, financial, and psychological access. Poor physical access covers everything from difficulty accessing services due to 1 Behavioral Health Research and Services, University of Alaska Anchorage. 2 Family and Community Medicine. 3 University of New Mexico School of Medicine. 4 UNM Health Sciences Institute for Ethics. 5 Department of Psychiatry and Behavioural Medicine, Medical College of Wisconsin. 6 Correspondence should be directed to Dr. Mark E. Johnson, Behavioral Health Research and Services, University of Alaska Anchorage, 3401 E. 42nd Street, Suite 200, Anchorage, AK 99508, USA; e-mail: mejohnson@uaa.alaska.edu. 504 0894-587X/06/0700-0504/0 Ó 2005 Springer Science+Business Media, Inc. 505 initiatives to remedy this situation (Ricketts, 1999). Health care availability can be adequately estimated by calculating how many providers practice per capita in a defined geographic region (Fortney, Rost, & Warren, 2000). Such per capital calculations have shown significant differences in the number of care providers per number of 100 people in the local population for rural versus urban areas, with rural areas being predictably disadvantaged (Rost, Fortney, Fischer, & Smith, 2002). The National Center for Health Statistics (NCHS, 2001) reports an average of 110 physicians per 100,000 residents in non-metropolitan areas and of 309 for metro areas. The more specialized the service provider, the worse the national per capita ratio (i.e., the fewer providers per given number of people or the more consumers per single provider). NCHS reports 54 specialists per 100,000 residents in non-metropolitan areas as compared to 189 in metro areas. Only general/family practitioners are found at slightly higher rates in non-metro as compared to metro areas (30 versus 27 per 100,000). Despite this prior work, state-level data have typically excluded Alaska and failed to explore provider disparities among specialty care groups relevant to the provision of mental health care. Prior research has documented that rural residents receive most of their health care in general and mental health care in particular from general physical care providers, such as primary care physicians, nurses practitioners, and physician assistants (American Psychological Association, 1995; Guralnick, Kemele, Stamm, & Sister Greving, 2003; National Rural Health Assocation, 1999). It is likely that this pattern is due to lack of specialized mental health car providers in rural areas, although rural residents have also been found to express preferences for generalist care providers over specialists (Barry, Dohery, Hope, Sixsmith, & Kelleher, 2000; Fox et al., 2001). The current study assessed rural area disparities compared to urban areas regarding provider availability in eight basic care arenas relevant to mental health care in two large rural states. We hypothesized that rural residents in Alaska and New Mexico have access to fewer providers in all basic health care and mental health care categories, but especially to those provider categories requiring the most advanced degrees (i.e., psychiatrists and psychologists) to qualify to provide mental health services. METHOD Provider Groups We obtained lists of licensed physicians (including several primary care sub-specialties), physician’s assistants, licensed nurse practitioners, registered nurses, psychiatry, psychology, social work, and licensed mental health care providers (such as licensed professional counselors or psychological associates or marriage and family therapists) from Alaska and New Mexico licensing boards in 2003. We focused only on these licenses as the first four are considered to be the primary licensed physical care providers most likely to encounter patients with mental health-related presenting problems; the last four are considered the primary licensed mental health care providers in rural areas. Procedures and Analyses We designated individuals on the eight lists as practicing in rural versus urban regions based on their address in the licensing list. Urban in Alaska was defined as Anchorage, Juneau, and Fairbanks (and their suburbs); in New Mexico, urban was defined as Albuquerque (and its suburbs), Santa Fe, and Las Cruces; and all other areas in both states were defined as rural. After preparing rural/urban provider frequency counts of providers for each state, we calculated rural and urban ratios of licensed providers to residents, using the most recent census numbers. To compare rural and urban regions with regard to provider availability and to quantify any differences, we calculated a disparity ratio, using the following formula: number of individuals served per provider in rural area divided by number of individuals served per provider in urban area (i.e., rural ratio/urban ratio.) RESULTS AND DISCUSSION Table 1 reveals large differences in the number of providers available in rural versus urban areas. As predicted, rural residents have fewer practitioners to draw upon than urban residents. This is particularly true the more education and specialization is required of the care provider. For example, minimal disparity is noted in terms of availability of physician 506 Table 1. Health Care Provider Disparities in Rural Versus Urban Areas of Alaska and New Mexico Alaska Rural (pop. = 255,703) Provider groups Physical health care Primary care physicians Family practice OB/GYN Emergency medicine Pediatrics Internal medicine Physician assistants Registered nurses Nurse practitioners Mental health care Psychologists Psychiatrists Social workers Mental health counselors** New Mexico Urban (pop.=379,819) Rural Urban (pop.=1,148,928) (pop.=680,218) Number Rate Number Rate Disparity Ratio* Number 200 137 5 16 19 23 101 1156 110 1:1279 1:1866 1:51,141 1:15,981 1:13,458 1:11,118 1:2532 1:221 1:2325 643 249 72 74 101 147 156 4084 325 1:590 1:1522 1:5267 1:5124 1:3754 1:2580 1:2431 1:93 1:1167 2.17 1.23 9.71 3.12 3.58 4.31 1.04 2.38 1.99 27 8 91 74 1:9470 1:31,963 1:2810 1:3455 109 79 306 299 1:3479 1:4800 1:1239 1:1268 2.72 6.66 2.27 2.72 Rate Number Rate Disparity ratio* 630 229 52 47 78 223 146 2,566 231 1:1824 1:5017 1:22,095 1:24,445 1:14,730 1:5152 1:7869 1:448 1:4974 1586 369 127 125 271 629 163 3581 329 1:429 1:1843 1:5356 1:5442 1:2510 1:1081 1:4173 1:190 1:2068 4.25 2.72 4.13 4.49 5.87 4.76 1.89 2.36 2.41 104 54 1122 680 1:11,047 1:21,276 1:1024 1:1690 366 229 1672 1370 1:1859 1:2970 1:407 1:497 5.94 7.16 2.52 3.40 *Disparity ratio=number of individuals served per provider in rural area divided by number of individuals served per provider in urban area. **Mental health counselors include professional counselors, marriage and family therapists, and psychological associates. assistants, the provider group with the lowest training requirements in the physical health care arena. This compares to large discrepancies in specialized areas of primary care medicine. For example, there is one OB/GYN physician in Alaska for over 50,000 rural individuals compared to one OB/GYN physician for 5000 urban individuals. Similarly, in the mental health arena, disparities among master’s level providers are much lower than among psychiatrists. For example, in New Mexico there is one psychiatrist per 20,000 rural residents whereas in urban areas there is one per 3000 residents. Even though our numbers suggest that Alaska evidences somewhat less disparity between rural and urban areas than New Mexico, the ratios fail to reflect the greater geographic access challenges encountered by Alaskan rural residents. Specifically, in Alaska, with a geographic landmass of 656,425 square miles (compared to New Mexico’s 121,593), one care provider may provide services in a geographic region as large as the entire state of New Mexico. Thus, although there may be a single care provider available for relatively fewer individuals than the New Mexican counterpart (e.g., one emergency medicine physician in Alaska per 16,000 individuals compared to almost 25,000 in New Mexico); such care delivery has to be delivered in a much greater and more challenging geographic region in Alaska. Our findings corroborate that rural residents face significant disparities for access to care providers, especially as educational requirements and need for specialization increase for the care provider. These disparities are a fact of life for rural residents, especially in very remote regions of states with frontier areas. Addressing these disparities is a crucial aspect of improving health care delivery in the United States for all populations. Creative strategies are needed to reduce these disparities, such as educational and financial incentives for rural care providers, rural recruitment of potential students in medicine and psychology, enhanced supervision of and support for non-disparate provider groups (such as physician assistants), updating of technology in rural areas to support telemedicine projects, and similar programs. ACKNOWLEDGMENTS The research was supported in part by grant 1RO1DA13139 from the National Institute on Drug Abuse. Dr. Roberts also gratefully acknowledges the support of a Career Development Award (1KO2MH01918) from the National Institute of Mental Health. 507 Appreciation is expressed to Marcine Mullen at the University of Alaska Anchorage and Dr. Pamela Monaghan and Audrey Solimon at the University of New Mexico School of Medicine for their invaluable assistance. REFERENCES American Psychological Association. Office of Rural Health (1995). 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