Primary Care Practitioners

The primary care (PC) practitioner definition used in this assessment is the same as that used in the ADHS Primary Care Area (PCA) Statistical Profiles documentation.[2] Primary care practitioners are defined as physicians (Allopathic Physicians (MDs) and Osteopathic Physicians (DOs)) and mid-level practitioners (Physician Assistants (PAs), Nurse Practitioners (NPs), and Certified Nurse-Midwives (CNMs)) with active licenses, residing in Arizona, whose primary or secondary specialty is one of the primary health care specialties: family practice (FP), general practice (GP), internal medicine (IM), pediatrics (PD), or obstetrics/gynecology (GYN, OBS, and OBG). Even though general surgeons (GS) provide primary care services, especially in the rural areas, they are not counted as primary care physicians by the PCA definition. In 2001, there were 4,349 primary care physicians and 2,860 mid-level practitioners (PA – 867, NP – 1,800, and CNM – 193).

A Primary Care Area is a geographic area in which most residents seek primary health services from the same place(s). The Arizona Department of Health Services PCA website provides the number of health care practitioners located in each primary care area as well as the location of the next nearest primary care service provider. (http://www.azdhs.gov/hsd/chpprofiles.htm).

Health Resources and Services Administration (HRSA) has defined a Primary Care Health Professional Shortage Area (HPSA) as an area that has a population to full-time equivalent primary care physician ratio of at least 3,500:1.[3] However, an area with unusually high needs for primary care services or insufficient capacity of existing primary care providers can have a ratio of 3,000:1. (Note: those graduates of foreign medical schools who are citizens or lawful permanent residents of the United States, but do not have unrestricted licenses to practice medicine, are counted as 0.5 FTE physicians.) The Arizona Primary Care HPSA area listing can be found at the ADHS website:http://www.azdhs.gov./hsd/hpsa.htm. In 2002, HRSA had conducted a 50 state survey on how each state has responded to the health worker shortage. The results are presented at: http://bhpr.hrsa.gov/healthworkforce/reports/stateresponse/default.htm.

Primary Care Physicians

In 2001, there were 4,349 active licensed primary care physicians in the state of Arizona. There was an increase of 528 primary care physicians (14%) from 1997 to 2001 (Figure 1 and Table 1 ). Although there was an increase in the overall number of primary care physicians, the increase did not keep up with the population growth during this period. The ratio of primary care physicians to 100,000 population decreased from 83.2 to 81.9 (Figure 2). There was a decrease in the primary care physician to population ratio in the two urban counties (91.1 to 89.2), while there were increases in the rural-urban (70.5 to 72.5) and rural-rural (53.1 to 54.4) counties. 

Although both allopathic and osteopathic physicians provide preventive, primary, and chronic care, osteopathic medicine differs from allopathic medicine by emphasizing the importance of normal body mechanics and manipulative methods of detecting and correcting faulty structure. There was a greater increase in the number of allopathic (MD) primary care physicians (+438 and 14%) than osteopathic (DO) physicians (+90 and 16%) from 1997 to 2001. Figures 3 through 6 and Tables 2 and 3 describe the state and county changes in the numbers of allopathic and osteopathic physicians during the five-year period. Arizona had 49 active primary care physicians per 100,000 population in 1998 (ranking 42nd out of 50 states), compared to 59 per 100,000 for the entire country¹. This was significantly lower than the state's overall physician ratio of 176 per 100,000 population (national rank of 30th)¹. 

Over the five-year period, the percentage increases for primary care physicians were greater in the 13 rural-urban and rural-rural counties (both at 19%) than in the two urban counties (13%). However, greater increases in the numbers of primary care physicians occurred in the two urban counties (+410) than in the rural-urban (+33) and rural-rural counties (+85). Of Arizona's 15 counties, four counties showed either no change or a decrease in the number or percentage of primary care physicians. These counties include: Gila (0 and no change), Greenlee (0 and no change), La Paz (-3 and -20%), and Santa Cruz (-4 and -17%). Apache (+11 and 69%) and Navajo Counties (+22 and 56%) showed the greatest percentage increases. 

Figure 7 and Table 4 summarize the state and county trends for obstetrics/gynecology physicians over the five-year period. There was an increase of 42 percent (+193) during this period, while the ratio of obstetrics/gynecology physicians increased from 46.1 to 58.0 per 100,000 women of child-bearing age (Figure 8). This increase occurred in all three county geographical areas (urban – 48.9 to 61.5, rural-urban – 45.2 to 59.5, and rural-rural – 32.2 to 39.4). The two urban counties (+164 and 43%) had greater percentage increases than the rural-urban and rural-rural counties (totaling +29 between the two and 39% for each). There were no obstetrics/gynecology physicians in Greenlee and La Paz Counties from 1997 to 2001. In Graham (2), Pinal (7), and Santa Cruz (4) Counties, there were no changes in the number of obstetrics/gynecology physicians during this five-year time period. The greatest increases in the number of obstetrics/gynecology physicians in the 13 rural-urban and rural-rural counties occurred in Apache (0 to 6) and Coconino (16 to 24).

Physicians Assistants

In 2001, there were 867 active licensed physician assistants (PAs) in Arizona. There was an increase of 437 physician assistants (102%) between 1997 and 2001 (Figure 9 and Table 5). During this period, the state's ratio of physician assistants to 100,000 population increased from 9.4 to 16.3 (Figure 10). Although this increase occurred in all three county geographical areas (urban – 8.5 to 15.6, rural-urban – 7.4 to 18.0, and rural-rural –13.5 to 19.1), the greatest increase occurred in the two rural-urban counties. PAs provide primary care services under the responsible supervision of a licensed physician. 

In 1999, Arizona had 11.0 PAs per 100,000 population which was higher than the Region IX average of 8.1 and the national average of 10.4 (ranking 27th out of 50 states)¹. Arizona ranks 17th out of 50 states in the total number of physician assistants. 69 percent of the PAs were employed in an ambulatory care setting compared to 61 percent nationwide. 88 percent of the physician assistants were White. Of the 12 percent of minority PAs, four percent were Hispanic/Latino, four percent were Black/African American, two percent were American Indian, and one percent was Asian American and Pacific Islander. 

Physician assistant percentage increases were also greater in the two rural-urban counties (+33 and 183%) than in the two urban counties (+331 and 110%) and the 11 rural-rural counties (+73 and 65%) during the five-year period. As expected, the greatest number increases occurred in the urban and rural-rural counties. Of the 15 counties, the number of PAs decreased only in La Paz (-2 and -50%). The other 14 counties showed increases in the number of PAs. Those counties with increases of at least 100 percent included Santa Cruz (+3 and 300%), Coconino (+18 and 257%), Yuma (+15 and 136%), Pinal (+18 and 129%), Maricopa (+301 and 123%), and Navajo (+7 and 100%). 

Figure 7 and Table 4 summarize the state and county trends for obstetrics/gynecology physicians over the five-year period. There was an increase of 42 percent (+193) during this period, while the ratio of obstetrics/gynecology physicians increased from 46.1 to 58.0 per 100,000 women of child-bearing age (Figure 8). This increase occurred in all three county geographical areas (urban – 48.9 to 61.5, rural-urban – 45.2 to 59.5, and rural-rural – 32.2 to 39.4). The two urban counties (+164 and 43%) had greater percentage increases than the rural-urban and rural-rural counties (totaling +29 between the two and 39% for each). There were no obstetrics/gynecology physicians in Greenlee and La Paz Counties from 1997 to 2001. In Graham (2), Pinal (7), and Santa Cruz (4) Counties, there were no changes in the number of obstetrics/gynecology physicians during this five-year time period. The greatest increases in the number of obstetrics/gynecology physicians in the 13 rural-urban and rural-rural counties occurred in Apache (0 to 6) and Coconino (16 to 24).

Nurse Practitioners

Both nurse practitioners (NPs) and physician assistants (PAs) are considered mid-level health care practitioners. In Arizona, there were more NPs (1,800) than PAs (867) in 2001. Nurse practitioners are registered nurses (RNs) who have completed additional training in specialty areas such as midwifery, pediatrics, family medicine, adult medicine, obstetrics-gynecology, neonatal medicine, and school nursing?. They are certified by the Nursing Board in one or more specialty areas that allow them to assume many of the routine tasks of a physician (e.g., prescriptive authority). In 1998, Arizona had 25.1 nurse practitioners per 100,000 population, which was slightly higher than the Region IX average of 24.

There was an increase of 721 active licensed nurse practitioners (67%) between 1997 and 2001 in the state of Arizona (Figure 11 and Table 6). During this period, the ratio of nurse practitioners to 100,000 population increased from 23.5 to 33.9 (Figure 12). This increase occurred in all three county geographical areas (urban – 24.6 to 36.4, rural-urban – 36.5 to 40.3, and rural-rural – 15.1 to 21.7). The greatest percentage increases occurred in the urban counties (+611 and 71%), followed by the rural-rural counties (+85 and 68%), and then the rural-urban counties (+25 and 28%). Of the 15 counties, only Apache and Greenlee showed decreases in the number of nurse practitioners during the five-year period, with Apache County showing a net loss of 3 and Greenlee County showing a net loss of 1 in the same time period. 

Certified Nurse-Midwives

Certified Nurse-Midwives (CNMs) are advanced practice, registered nurses (RNs) who have received additional education and training in midwifery – the care of essentially healthy and normal mothers during pregnancy and childbirth. The nurse-midwife provides care for the normally healthy mother during pregnancy and stays with her during labor, providing continuous physical and emotional support?. CNMs evaluate and provide immediate care for the normally healthy newborn, and help the mother to care for her infant and to adjust the home situation to the new child. Nurse-midwives are permitted to deliver the babies of low risk mothers, in hospitals and under the supervision of a physician – generally an obstetrician. 

There were 193 certified nurse-midwives in 2001. There was an increase of 65 CNMs (51%) between 1997 and 2001 (Figure 13 and Table 7 ). During this period, the number of certified nurse-midwives in Arizona increased from 12.9 per 100,000 women of child-bearing age to 17.2 (Figure 14). There was a decrease in the nurse practitioner to population ratio in the two rural-urban counties (33.1 to 31.4), while there were increases in the urban (11.9 to 15.5) and rural-rural (10.5 to 20.9) counties. In 2000, Arizona had 2.7 CNMs per 100,000 population which was higher than the Region IX average of 1.7 and the national average of 2.1.1 Arizona ranked 17th among the 50 states in certified nurse-midwives per 100,000 population.[1] 

During the period from 1997 to 2001, the greatest percentage of increases in the numbers of CNMs occurred in the 11 rural-rural counties (from 16 to 36, an increase of 125%), followed by the two urban counties (93 to 138, an increase of 48%). There were no changes in the two rural-urban counties (remaining at 19). Reflecting the situation with obstetrics/gynecology physicians, there were no certified nurse-midwives in Greenlee and La Paz Counties from 1997 to 2001. Yuma was the only county to show a net loss of CNMs (-2). In 1997, there were five counties with no CNMs. In 2001, three of these five counties showed a net gain of either 1 or 2 CNMs. These counties were Gila (0 to 2), Graham (0 to 1), and Santa Cruz (0 to 1).6 and slightly lower than the national average of 26.3 (putting Arizona 30th among the 50 states)¹.