TUCSON.COM | Patty Machelor | Jan 21, 2022

Arizona urgently needs doctors who provide basic and routine care — and that’s likely to increase dramatically over the next decade as the state’s population continues to grow and an increasing number of physicians reach retirement age.

For low-income residents and those living in rural areas, the outlook is especially dire.

Nearly 3 million Arizona residents live where there’s limited access to primary care doctors, said Dr. G. Richard Olds, a national expert on the physician workforce and president of St. George’s University medical school.

This, coupled with about one-third of the state’s doctors being over age 60, means there needs to be at least 1,000 more primary care doctors in Arizona by 2030 to keep up with residents’ needs.

These findings are reflected in the Association of American Medical Colleges’ recent report. It shows that, nationally, the highest number of physicians per capita is concentrated in the northeast while states in the south and west tend to have lower ratios. This includes both medical doctors and doctors of osteopathy.

The data shows an average of 287 physicians with active licenses per 100,000 residents nationally in 2020, ranging from a high of 466 doctors per 100,000 residents in Massachusetts to 196 per 100,000 in Idaho. Arizona is ranked 31st with 252.

But just because a physician has an active license doesn’t mean direct patient care is part of that physician’s job.

When it comes to doctors providing direct care — instead of conducting research, for example, or doing administrative work — Arizona averages even lower, with about 230 doctors per 100,000 residents.

And for primary care physicians actually seeing patients, Arizona ranks 40th, with only 74 doctors per 100,000 residents.

“Arizona has a significant shortage of physicians, really, from top to bottom,” said Dr. Daniel Derksen, a professor of public health in the Mel and Enid Zuckerman College of Public Health at the University of Arizona.

Arizona meets just 37% of its primary care provider need, as more than 650 additional full-time primary-care doctors are needed, Derksen and Bryna Koch, a UA doctoral student in public health policy and management, found in their research.

The problem is compounded by the fact that Arizona is the fourth-fastest growing state in the nation, Derksen said, and Phoenix is the fastest-growing large city nationwide.

Using 2019 state licensure data, Derksen and Koch found there to be 16,947 active physicians statewide compared to the Association of American Medical Colleges’ finding of 18,343.

The UA researchers found the ratio of doctors providing care to patients in Arizona to be similar, however: 236 doctors per 100,000 residents compared to the AAMC finding of 231 per 100,000.

An additional challenge for Arizona is that federal funding for postgraduate medical training, commonly called residency spots, was capped in 1997 and there are not enough subsidized residency positions here now, Derksen said. As a result, many Arizona medical school graduates leave the state for their residency and then don’t come back.

Arizona’s situation is similar to what’s happening in California, Olds said, explaining that there’s a surplus of doctors in the cities and a serious deficit in rural areas.

“Some areas of Los Angeles have twice as many doctors as they need,” he said. One of the key answers, he said, is to recruit prospective doctors from underserved areas.

“You have to find a way to find more people who are born and raised in the physician shortage areas,” he said. The work needs to be done in those high schools and colleges, to get them excited to go into medicine, he said.

Derksen agrees, and wants to see more diversity in the state’s medical programs.

“When we focus on the physician workforce, certainly the percentage of (minority doctors and students) does not reflect the diversity of the population in the state of Arizona,” he said. “We’ve made some progress on that front, but much more needs to be done.”

Other findings in the AAMC report:

Female physicians make up 36.7% of the nation’s active physicians;

About 33.7% of the nation’s physicians are aged 60 and older while only about 16.3% are under 40;

About one-quarter, or 24.7%, of active physicians in 2020 were international medical graduates, meaning they graduated from a medical school outside the United States, Puerto Rico, or Canada;

There were 92,670 students enrolled to become medical doctors in 2020-21 and 31,663 enrolled to become doctors of osteopathy in 2019-20 for a combined increase of 30.2% since 2010-11.

From the Whitehouse Briefing Room: the first ever Presidential Proclamation marking this important day.

NOVEMBER 17, 2021 • PRESIDENTIAL ACTIONS

America’s rural communities feed and fuel our country, steward our precious lands, and are home to 1 out of every 5 Americans.  As we continue to fight the COVID-19 pandemic and make the investments we need to build back better, we must ensure that our recovery includes and strengthens our Nation’s rural communities.  On National Rural Health Day, we recommit to supporting the health and well-being of rural Americans and celebrate the rural health care providers who work tirelessly to meet their needs.

Rural Americans face unique challenges accessing the care they need and deserve.  They often have to travel greater distances to see a health care provider, are less likely to have access to broadband to utilize telehealth services, and are more likely to live in an area that has a shortage of doctors, dentists, and mental health providers.  While the impact of the COVID-19 pandemic has spared no part of the country, rural areas have confronted additional challenges that affect the delivery of services, including limited health care infrastructure and fewer clinicians.

My Administration is committed to improving the health of rural communities and ensuring that those who call these communities home have equitable access to the resources and services routinely available to people living in more densely populated areas.  That is why my American Rescue Plan (ARP) is providing $8.5 billion to rural health providers to keep their doors open and continue responding to the COVID-19 pandemic.  This builds on over $820 million in ARP spending from earlier this year to support COVID-19 testing and mitigation across 4,200 Rural Health Clinics and over 1,500 small rural hospitals and $100 million in ARP funding to support the vaccine outreach efforts of Rural Health Clinics.  My Administration’s plan also provided $500 million to create the Emergency Rural Health Care Grant Program, which is helping rural communities provide more COVID-19 testing and treatment, purchase medical supplies, deliver food assistance, and renovate health care facilities.  These investments are complemented by funds to expand telehealth and support training for new rural health care providers, including community health workers and respiratory therapists.  This funding has supported thousands of Rural Health Clinics, small rural hospitals, and community health workers.

My Administration’s Build Back Better framework will build on the successes of the ARP by delivering lower cost, higher quality health care to rural Americans.  My Administration’s proposal is the biggest expansion of affordable health care in a decade and will lower prescription drug and other health care costs for rural Americans, keep rural hospitals open, and work to address the root causes of poor health, including outdated drinking water infrastructure across rural America.  Additionally, my Administration is coordinating efforts across Federal, State, Tribal, territorial, and local governments and incorporating health equity principles, policies, and approaches in our efforts to better support rural communities.  This means supporting rural hospitals and clinics, expanding telehealth and workforce development, improving community health, and providing greater access to capital so that every American can receive lower cost and higher quality health care. 

On National Rural Health Day, we recognize the importance of the health and well-being of our rural communities.  As our Nation builds back better, we recommit to supporting our rural health care providers and working together to bring about a stronger, healthier rural America.

NOW, THERFORE, I, JOSEPH R. BIDEN JR., President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim November 18, 2021, as National Rural Health Day.  I call upon the people of the United States to reaffirm our dedication to the health and well-being of rural America.

IN WITNESS WHEREOF, I have hereunto set my hand this
seventeenth day of November, in the year of our Lord two thousand twenty-one, and of the Independence of the United States of America the two hundred and forty-sixth.

JOSEPH R. BIDEN JR.

KAWC NEWS Arizona Edition with Lou Gum | Oct 29, 2021

A proposed joint venture between Yuma Regional Medical Center and hospital management company, LifePoint Health, a holding of the Apollo Management Group, a private equity firm, would change the hospitals' not-for-profit status to a for-profit model. 

Today on Arizona Edition, host Lou Gum speaks to Dr. Daniel Derksen, Professor of Public Health, Medicine and Nursing at the University of Arizona's Mel and Enid Zuckerman College of Public Healthand Director of the University's Arizona Center for Public Health.  

Derksen discusses various hospital ownership and management models, including the fairly recent introduction of private equity firms into the ownership landscape. He says a lack of data makes it hard to assess whether a not-for-profit or non-profit hospital is better for a community than a private, or corporate-owned entity, in part due to mandated reporting and health metrics for one group and less transparency or required accountability for the other. 

Derksen suggests the "important decision" by a community to change its hospital's legal framework should be based on the transparency and accountability of hospital leadership, their commitment to addressing local health needs, and an on-going dialogue with community members. 

» Listen: https://cpa.ds.npr.org/kawc/audio/2021/10/azed_web_102921.mp3

Cronkite News Arizona PBS | Oct 22, 2021

WASHINGTON – More than 40,000 Arizonans signed up for Affordable Care Act health insurance in the six-month special enrollment period earlier this year, and advocates expect the numbers to keep rising in the enrollment period that opens next month.

The difference, they say, is a White House that’s not antagonistic to the ACA – also known as Obamacare. 

While the Trump administration cut funding and shortened enrollment periods, President Joe Biden has invested heavily in boosting enrollment. As a result, more than 12.2 million Americans now have insurance through the ACA marketplace, almost 200,000 of them in Arizona.

“The previous administration cut navigator grant funding and marketing by 90%,” said Allen Gjersvig, director of outreach and enrollment services for the Arizona Alliance for Community Health Centers. “But the current administration has invested more in the navigator program than at any other time.”

One of the first things Biden did was to create a special open enrollment period, which ultimately ran from Feb. 15 to Aug. 15. That was well beyond the typical fall open enrollment period for people seeking coverage for the following year, which had been cut to as little as six weeks under President Donald Trump.

The Centers for Medicare and Medicaid Services said that 2.8 million new customers took advantage of the special enrollment period this year to get health insurance, 40,827 in Arizona.

The extension “gave people plenty of time to hear the message,” Gjersvig said.

The Biden administration also allocated $80 million in grants to marketplace “navigators” for the 2022 plan year, money that will go toward outreach and education to help people understand the coverage they qualify for.

“It’s encouraging that the word is finally getting out,” said Jim Hammond, a publisher at the Hertel Report, which follows Arizona health care. “But word is slow to get out.”

Hammond said he expects the number of people enrolling through the marketplace will continue to grow during the regular open enrollment period for 2022 coverage, which opens Nov. 1. It wil close on Dec. 15 for people who want coverage to begin Jan. 1, but will remain open until Jan. 15 for everybody else.

“I expected them to at least get back to where they were at our highest peak,” Hammond said of the marketplace enrollment numbers. “But we really can get higher than that.”

Many people choose not to enroll because they believe they cannot afford health care, but the ACA was created specifically to lower costs and expand access to health care, Hammond said. He encouraged people to go to a navigator like Cover Arizona or to use tools like the Kaiser Family Foundation’s calculator that estimate how much financial assistance a person may qualify for, based on their income, family size and more.

“There’s still a lot of people out there who are eligible for no-cost coverage, but they just have not tried,” Gjersvig said.

Hammond said another problem is the stigma around public health insurance that dissuades people from enrolling, something navigators will have to work against.

“The sad thing is that many of these people eventually face a medical emergency that will put them over the edge,” Hammond said. “This could have been avoided if they had health insurance.”

The Census Bureau said that 11.3% of people in Arizona were uninsured in July 2019, compared to 9.2% in the U.S. who were uninsured at the same time.

Dr. Daniel Derksen, director of the Arizona Center for Rural Health, said that “while the trends are very promising…we still have some work to do.” Many uninsured Arizonans are still unaware of how health insurance works, and it is “up to navigators to help them understand what they’re eligible for,” Derksen said.

“There’s about 750,000 Arizonans who lack health insurance,” he said. “Roughly half of them are eligible for coverage and they may just not know it.”

But Derksen and other experts are optimistic that more and more people will sign up when they understand the system.

“If word gets out, and people understand and believe what they’re hearing, we would hope that the numbers in Arizona would continue to grow,” Gjersvig said.

» Complete article at link below, or download PDF

By Daniel Derksen, in ARIZONA PHYSICIAN, Maricopa County Medical Society | Summer Issue 2021

One in five Americans lives in a rural area. Yet it’s been 25 years since the U.S. invested in its rural health infrastructure through Hill Burton funding (1947-1997) based on community need. While 18-20% of the nation’s population lives in a rural area, just 10% of primary care physicians and 7% of specialist physicians reside there.

Moonshot

The Great Society Programs of the 1960s intended to address the 25% of Americans living below the Federal Poverty Level, and even higher (33% below FPL) in rural areas, and included creating a Job Corps, Head Start, Medicare, Medicaid, and other programs to expand affordable health care, education, and housing. Over that decade rural poverty dropped to 17.9%.

Investments in individual health insurance coverage started with amendments to the Social Security Act that created Medicare and Medicaid in 1965, added the Children’s Health Insurance Program in 1997, and in 2014 expanded Medicaid and subsidized private health insurance for 20 million Americans via the Affordable Care Act. These investments helped stabilize finances in rural hospitals and clinics. However, many community clinics, rural and critical access hospitals operate on thin margins without reserves to weather economic downturns.

Upshot

In 2021, intractable rural versus urban socioeconomic and health disparities persist.

Rural counties are often defined simply as having a population of less than 50,000. There are more precise designations such as federal-state determinations for Health Professional Shortage Areas, Rural Urban Commuting Areas (RUCAs), and other sub classifications.

Rural America is demographically and economically diverse, suggesting that while some commonalities exist (rural populations tend to be older, have lower incomes, and higher rates of certain chronic diseases), policy and programmatic interventions should be customized to meet diverse rural community needs. While rural age adjusted death rates per 100,000 are improving for cancer, coronary heart disease and stroke – they are not improving as much as in metro areas. Rural death rates are worsening for COPD, diabetes, unintentional injury and suicide.

Of the 69 million Americans living in rural areas, 13 million are people of color, and 2 million are immigrants. Rural residents who are Black, Latinx/Hispanic and American Indian have social determinants that contribute to poorer health outcomes including higher rates of poverty, lower educational attainment, and less access to affordable housing and health insurance coverage and services.

» Continue reading at the link below:

Katya Mendoza, Special to Tucson Local Media | Aug 4, 2021

University of Arizona’s Arizona Center for Rural Health has received a five-year, multi-million dollar grant from state and federal sources to continue their mission of providing health care, education, technical assistance, data analyses and more to rural communities throughout the state.

The Arizona Center for Rural Health aims to support the state’s rural and underserved populations by supporting a number of UA-based programs, including the Arizona State Office of Rural Health, the Arizona First Responders Initiative, the Small Rural Hospital Improvement Program and the Rural Hospital Flexibility Program.

Jennifer Peters, associate director and program coordinator for AzSORH who oversees the day-to-day operations of the program at the state and national levels, says that every federal dollar has to be matched with three state dollars.

The funding period began on July 1, 2021, and ends June 30, 2026. The total amount of the federal award including approved cost sharing or matching this project period was

$223,410, which was matched by the state with $670,230, resulting in a total of $893,640, set to be dispersed each year.

The majority of these funds on an annual basis are used to support a staff of 15 within the AzSORH office, with positions in program oversight, community outreach, training and education or health systems development, with some some funds allocated for travel.

“A lot of our efforts go around helping collect and disseminate rural health information, education events and training,” said AzCRH director Dr. Daniel Derksen.

One major challenge: An increasing shortage for primary care physicians in rural parts of the state. According to the AzCRH, Arizona meets only 41.7% of its PCP need. While the majority of the primary care doctors within the state of Arizona live in urban metro areas such as Maricopa and Pima counties, they are aging especially in rural and underserved areas. The AzCRH seeks to place and retain physicians in these areas in order to create jobs and improve access to health care as an effort to lower the cost in these low income and underserved communities.

Other factors affect overall rural health outcomes, such as socioeconomics, lack of health insurance coverage and infrastructure. The AzCRH has helped create 15 federally designated critical access hospitals, 24 federally certified rural health clinics, and 160 federal qualified health centers that are part of the state and federally funded “health safety net.”

The center, previously known as the Rural Health Office, has been housed within the University of Arizona Mel and Enid Zuckerman College of Public Health for the past 30 years.

Since 1990, AzCRH has participated in a five-year cycle in which they are required to submit a full application to show that they have conducted a needs assessment and that they have designed a program that has responded to the needs of a rural community. In order to convey these accomplishments, they must ensure that what they propose addresses specific guiding principles.

The AzCRH looks at rural communities that are unique and not homogenous, with a focus on tribal and the US Mexico border populations that will also have their own subsets variations.

“We have to ensure that everything we do addresses those variations and that are sensitive to the different needs, culture, history, the different capacities that are in all of those communities,” said Peters. “We really like to emphasize sort of a holistic view of rural health that integrates not just individual health behaviors, but also the social and structural determinants of health that exist in a community.”

Certain challenges exacerbated by the pandemic have disproportionately affected the more elderly populations in rural areas, such as the Navajo and Apache nations as well as the Santa Cruz, Cochise and Yuma counties. Both Native Americans and Hispanic populations face significant health disparities due to their isolation from in-person health care services.

“Arizona is a very large state, we have most of our population in the Pima and Maricopa counties. One in four live in the other 15 counties in the state, and a lot of our efforts focus on [these] other counties,” said Derksen.

These rural areas were hit hard by the pandemic due to the volume of patients and amount of people reluctant to seek health care. Despite the decreasing rate of outpatient visits, AzCRH was able to assist in the set-up of telehealth for primary care, rather than in person care for these communities.

“A lot of the rates of infection were high, if you only have 25 beds, you can quickly be overwhelmed by an outbreak of COVID-19,” said Derksen.

While rural communities were inordinately affected by the rise in death rates brought on by the pandemic, the AzCRH in collaboration with the AZDHS, was able to set up testing sites, provide vaccinations, and information regarding the pandemic in a “culturally congruent” manner.

The AzCRH will use this funding to continue to monitor and assist the underserved communities throughout the state.

By Dr. Howard J. Eng, Associate Professor in Public Health (retired) 

It has been more than 4 months since Arizona Reopening Phase 3 that began on March 6, 2021. As more people are vaccinated and those infected recovered and have immunity against the virus, the numbers of cases, hospitalizations, and deaths will be low, and we will be able to return to normal. 

On July 9, 2021, more than 6.6 million COVID-19 vaccine doses had been administered in Arizona (AzDHS). There were 3,192,966 (43.8%) in Arizona and 432,506 (41.1%) in Pima County who are fully vaccinated. Figures 1 and 2 show the numbers of vaccines given in Arizona and Pima County (total doses given, persons receiving at least 1 dose, and persons fully vaccinated).   

Since the last week of Arizona Reopening Phase 2 (February 28 to March 6), there have been significant decreases in COVID-19 cases and deaths in the state and Pima County.  A case can be mild (no symptoms), moderate (sick, but can recover at home), and severe (require hospitalization and/or result in death). Most people recover and do not require hospitalization. Tables 1 and 2 show the Arizona and Pima County total and weekly coronavirus case, hospitalization, and death numbers during February 28 to March 6 and the last four weeks.  

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