Report details reasons for Arizona physician shortage

A new study on Arizona's doctors by the Goldwater Institute concludes that the doctor shortfall is caused by "misguided" federal policies that need changing.

By Jay Greene, amednews staff. Dec. 10, 2001.

Fewer doctors have been attracted to Arizona in the past decade primarily due to federal policies on emergency care, health insurance and immigration, says a study from the Goldwater Institute, a Phoenix-based conservative public policy group.

Licensing data from the Arizona Board of Medical Examiners show that the state had 185 patient-care physicians per 100,000 population in 2000, a 6.6% decline compared with 198 in 1990, said Jeffrey Singer, MD, a study co-author. The national average was 238 in 1990 and 228 in 1999, a 4.2% decline, according to the AMA Physician Masterfile.

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"The last few years physicians here have noticed that a shortage is developing," said Dr. Singer, a general surgeon who is on the board of the Goldwater Institute. "My office looks like a pediatrician's. We double and triple book. Sometimes I get patients referred to me with problems requiring surgery that should have been done two months ago."

Arizona isn't the only state where there appears to be shortages. State medical associations have voiced concern about recruiting and retaining doctors in Michigan, Ohio, Massachusetts, West Virginia, Mississippi, Washington, Oregon and California. Some specialty societies also have predicted shortages of anesthesiologists, gerontologists, cardiologists, pulmonologists, urologists, oncologists, gastroenterologists, orthopedic and general surgeons, hematologists and a variety of intensive care physicians.

"This report substantiates what we have been hearing about anecdotally [for about three years]," said Chic Older, executive vice president with the Arizona Medical Assn. Older said a combination of large numbers of undocumented immigrant workers, low reimbursement rates, an elderly population and a high percentage of uninsured residents has created a crisis in Arizona.

"It is like the perfect storm," Older said. "This whole medical system is on the verge of collapse."

Despite Arizona's attractive climate and lifestyle, Dr. Singer said an increasing number of Arizona physicians are quitting, selling their practices, moving to other states, retiring at earlier ages or cutting hours.

"We expected managed care to be the bad guy, but it looks like our high uninsured rate and federal immigration policies are having more of an effect on border states like Arizona," Dr. Singer said. "This causes a 'hidden tax' on physicians that makes our state economically unappealing for doctors."

Arizona's uninsured rate is 23%, which is tied for second in the nation with New Mexico and behind Texas at 24%. The national uninsured rate is 16%. Arizona also ranks third in noncitizen Mexican population at 20.8%, behind Texas at 24.3% and California at 25%. The national average for all noncitizens is 6.5%.

According to a salary study in the Sept. 18, 2000, issue of Medical Economics, physicians practicing in the Rocky Mountain region, including Arizona, earned an average net income of $160,470 in 1999. Of the nation's nine regions, the only regions with a lower average net income than Rocky Mountain were New England at $155,540, Great Lakes at $151,530 and the Far West, including Alaska and Hawaii, at $152,280.

Although compensation is lower in Arizona than other states, Dr. Singer said liability insurance rates, managed care penetration rates, and Medicare and Medicaid coverage are similar to national averages.

But one of the nation's leading physician work force experts, Richard "Buz" Cooper, MD, director of the Health Policy Institute at the Medical College of Wisconsin in Milwaukee, said he thought Arizona's physician shortage was related more to the nation's growing physician shortage than the higher-than-average uninsured rate. The shortage may be worsened in Arizona by unexpected population increases the past decade, he said.

Population booming

Arizona's population has grown nearly 38% from 3.7 million in 1990 to 5.1 million in 2000, federal census data show. During that period, in-state physicians increased 29.7% to 9,474 from 7,306, the report said.

But by subtracting out physicians working in administrative positions and retired physicians, the adjusted physician-patient ratio was 172 in 2000. While physicians working in administrative jobs remained the same, at about 1% of the total from 1996 to 2000, the number of retired physicians increased to 6% in 2000 from 5% in 1996, the report said.

"I'm not sure that the insurance market and other issues cited in the report necessarily had much to do with it, but they may have had some secondary effect," Dr. Cooper said. "If there was a national surplus like the one that everyone has been talking about, physicians would be flocking to Arizona regardless of the insurance market."

Tips from the institute

The report, "Keeping the Doctor Away: What Makes Arizona Unattractive to Physicians," is available at the Goldwater Institute Web site (http://www.goldwaterinstitute.org/). Its suggestions include:

Phasing out mandated insurance benefit laws. Mandated benefits laws increase the cost of health insurance and consequently also the number of uninsured.
Expanding and removing restrictions on medical savings accounts. Of the nearly 100,000 Americans who have purchased MSAs since the program began in January 1997, more than a third had been previously uninsured.
Enacting a universal tax credit for health insurance.
Reforming immigration laws to allow Mexicans or other immigrants to work in the United States but retain their home country's health insurance benefits.
Repealing the Emergency Medical Treatment and Active Labor Act, which significantly affects Arizona physicians because of the state's high uninsured rate. The AMA, the ArMA and other health care groups want Congress to reverse some EMTALA provisions. The U.S. Dept. of Health and Human Services is studying the problem.