Access to health care professionals in rural Mississippi. (Original Article).

Background: The location and identification of health professionals' practice sites is the first step in enhancing the availability of quality medical care to all regions of the state. Identification of specific areas of need is difficult, as provider data is often collected and housed separately through multiple organizations. This study provides a comparative review of the distribution of physicians, dentists, nurses, and psychologists and examines future provider needs of selected rural counties and regions within the state.

Methods: Data were compiled from multiple state and federal agencies.

Results: Twenty percent of Mississippi physicians are at or near retirement age. Several Mississippi counties could lose most or all of their physicians in the next few years. The distribution of health care workers is uneven across the state.

Conclusion: Maldistribution of health care workers and the aging health care workforce impacts access to care, particularly in rural Mississippi counties.

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Mississippi is a rural state facing a major shortage of health care professionals, particularly for citizens in small, isolated communities. A slow economy and sparse population base impact many health care providers' decisions to work in these sites. Limited opportunities for continuing education and dialogue with colleagues leave many health care professionals feeling isolated. (1) In addition, such rural providers have limited access to medical facilities that are equipped to handle patients needing acute care. Recruiting health care professionals to rural areas is a growing problem, not only within this rural state, but nationally. (2) Because provider data are often collected and housed separately through multiple agencies, identification of counties or agencies with specific personnel needs is a reciprocal problem.

The purpose of this study is twofold: 1) to provide a comparative review of the distribution of primary care physicians, dentists, nurses, and psychologists across the state; and 2) to assess future provider needs of selected rural counties and regions within the state.

Mississippi's population of nearly 3 million is unevenly distributed across the state. Twelve counties have population densities greater than 50,000; 35 of the 82 counties have fewer than 20,000 residents, and 10 counties have fewer than 10,000 individuals. The state's population is 64% white and 36% black, with 53% of the black residents living in rural areas. Despite the low density of populations within these rural counties, the state still has 62 of its 82 counties deemed as either full or partial health professional shortage areas (HPSAs) by the federal government; 67 counties are designated primary care HPSAs; 36 counties are deemed dental HPSAs, with an additional 4 counties holding partial designation. (2a) Such designations reflect the Council on Graduate Medical Education's 10th Report (2b) highlighting the continued maldistribution of health care providers. In addition, these figures are in sharp contrast to the federal government's Healthy People 2010 objectives, which target access to a health ca re provider for at least 88% of the country's population. (3) According to data from the Health Resources and Services Administration (HRSA) publication State Health Workforce Profiles, there are 43 primary care physicians per 100,000 population in Mississippi, compared with 59 per 100,000 for the nation. (4) These statistics do not represent the true picture of the maldistribution of health care providers within our rural communities, however.

Methods

Data for this study were compiled from multiple sources: 1) Mississippi State Board of Medical Licensure, 2) Mississippi State Board of Health, 3) University of Mississippi Medical Center departmental records, 4) Mississippi State Board of Nursing, 5) U.S. Department of Health and Human Services, 6) U.S. Bureau of Census, and 7) Mississippi Department of Mental Health.

Results

Primary Care Physicians

Recruitment and retention of primary care practitioners (family practice, general practice, internal medicine, obstetrics/gynecology, and pediatrics) for rural settings continue to be a major concern within Mississippi. (1) A recent study by Forbes et al (5) surveyed graduates of primary care residency programs at the University of Mississippi Medical Center regarding the status of their practice. Results of the study showed that 100% of graduates are continuing to practice, as well as maintaining family medicine as their principal area of emphasis.

Currently, 5,494 primary care physicians practice in Mississippi, with more than half (3,293) of them practicing in only 7 counties. Twenty-two percent of the physicians (family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology) practice in Hinds County, the site of the state capital. As Figure 1 shows, 36 counties have 10 or fewer primary care physicians providing health care services; 19 counties have 5 or fewer primary care physicians. Largely family practice physicians and general practitioners serve the more rural counties; in counties with fewer than 25,000 population, family practice physicians and general practitioners constitute an estimated 85% of the primary care physicians. In 6 counties (Benton, Carroll, Clay, Greene, Humphreys, and Issaquena), there are no family practice physicians serving the more than 64,000 rural citizens. An additional 30 counties have 5 or fewer family practitioners.

Figure 1 shows the maldistribution of primary care physicians across the state and highlights the need for recruitment and retention of physicians from and in rural communities. Such recruitment increases the likelihood that graduates will return to practice in rural (6-8)

Moreover, of the total number of licensed physicians in Mississippi, 1,077 (20%) are at or nearing retirement age (Table 1). Table 2 shows specific counties that could lose all, or at least the majority, of their practitioners to retirement within the next 5 to 10 years, and highlights the maldistribution of physicians on the basis of county population. (8a)

Nursing Professionals

According to data from the Registered Nurse Population: National Sample Survey: March 2000, (9) Mississippi has 750 nurses per 100,000 people. This figure is lower than the national ratio of 782 per 100,000, and does not speak to the maldistribution of the nursing workforce across the state.

Mississippi has 21,660 employed registered nurses (RNs) and 9,251 licensed practical nurses (LPNs). Women comprise 92% of the R.N population; 86% are white and 13% are black. Nurse practitioners also work within the state, serving in many rural communities through community health clinics, rural health clinics, physicians' offices, private clinics, and other primary care practice settings. In 1999, there were 941 RNs certified for expanded-role nursing as nurse practitioners: 43 adult medicine, 488 family practice, 344 certified registered nurse anesthetists, 4 family planning, 5 gerontologic, 18' neonatal, 22 obstetrics/gynecology, 25 pediatric, and 15 women's health nurse practitioners.

America has an aging population that relies heavily on nursing services to manage chronic conditions. (9) As in the nation as a whole, 12% (n = 332,235) of Mississippi's population is 65 years of age or older. Similarly, the nursing workforce is aging. Of Mississippi's current nursing workforce, 5,223 (22%) are 50 years of age or older. According to the National Sample Survey data, the average age of the RN population is estimated to be 45.2 years, with the average age of RNs in the workforce increasing from 42.3 years in 1996 to 43.3 years in 2000. (9) These data suggest that only 31.7% of the RNs were younger than 40 years of age, with only 1 in 10 younger than 30 years. Such decline in the age groupings for the RN population reflects a decreasing enrollment in baccalaureate programs, a downward trend that has continued during the past 5 years.

Mississippi has 23 undergraduate (baccalaureate and associate degree) and 5 graduate nursing education programs that prepare professional nurses for teaching, administration, or clinical practice. Of the 23 undergraduate programs, 16 are located in community colleges, whereas 7 are located in state or private colleges or universities. During the 1999 academic year, 1,258 candidates from the various programs took the licensure examination, with 1,067 (85%) receiving a passing score. According to the Mississippi State Health Plan, because of the growing diversity in medical practice settings, the expanding use of home health services, and the increasing complexity of hospital care, nurses of the future will need even more education and skills than in the past. (9a) The nurses' roles continue to change in response to the complex system of health care delivery and population needs. Such increasing complexity and workplace demands affect the continuing shortage of nurses within the workforce for the state, as well as the nation.

Dentists

According to Mississippi licensure data from 2000, 1,462 dentists were licensed in the state, with 1,237 licensed in general dentistry. Of the total number of dentists, 1,183 were active practitioners. (11) Nine counties had only I dentist each, and 7 more counties (Alcorn, Benton, Humphreys, Issaquena, Jefferson, Sharkey, and Tunica) had no dentists serving the more than 76,000 citizens living within their rural boundaries.

The Surgeon General's report on oral health (12) cites the relationship between oral health and general well-being, and identifies a "silent epidemic" of dental and oral diseases that affects specific population groups. Individuals suffering the worst oral health, and subsequent restrictions to the overall quality of life, include the "poor of all ages, with poor children and poor older Americans particularly vulnerable." (12) In fact, children living below the poverty level (income less than or equal to $17,000/yr for a family of 4) suffer twice as many dental caries and have more severe and untreated decay than children from more affluent households. (13) According to the Surgeon General's report, more than 51 million school hours are lost each year to dental-related illness. (12) Poor children suffer nearly 12 times more restricted activity than children from higher income families. In addition, the lack of access to dental care affects our state's adult and geriatric populations. Twenty-three percent of t hose aged 65 to 74 years have severe periodontal disease. Many older adults take prescription medications that cause side effects that exacerbate oral health problems. Poor oral health affects the overall health of each individual. Severe oral disorders may negatively affect self-image and self-esteem, which may lead to chronic stress and depression and negatively affect the individual's ability to find and keep a job.

Psychologists

Access to psychologists in rural areas of the state is limited. (14) Psychologists are practicing in only 26 of the state's 82 counties, with the majority practicing in urban counties. Additional health care professionals, such as licensed clinical social workers (n = 522), licensed professional counselors (n = 555), and Department of Mental Health professionals (n 768), provide access to mental health care for the citizens across the state. Currently, 15 regional community mental health centers and 2 community service divisions provide access to mental health care for citizens in the state. The 15 mental health regions have a primary office, along with satellite centers in counties within their region. Services typically include but are not limited to 1) outpatient care, 2) medication and evaluation, 3) monitoring, 4) psychobehavioral rehabilitation, 5) emergency care, and 6) family education or support. (15)

Two comprehensive psychiatric treatment centers are located in the central part of Mississippi, at Whitfield and Meridian. Two acute regional psychiatric hospitals for adults are located in the northeastern and southern areas of the state. Under construction is a 50-bed facility for youth in Harrison County. In addition, 7 crisis centers are under construction. These 17-bed facilities will be strategically located throughout the state (Corinth, Batesville, Brookhaven, Cleveland, Grenada, Laurel, and Newton). Figure 2 shows the distribution of the health professional workforce (physicians, nurses, dentists, and psychologists) by county.

Conclusions

As the data show, Mississippi suffers from a maldistribution of its health care workforce. Attention must be paid to the aging of our workforce population and its impact on access to care, particularly in Mississippi's rural communities. This study identifies the lack of health care providers for residents of rural areas in Mississippi. Identification of these areas is the first step in enhancing the availability of quality medical care to all regions of the state.

Table 1

Active physicians in Mississippi 50 years of age or older by medical
specialty (a)

Physician          Family   General   Internal
age (yr)          Medicine  Medicine  Medicine  Ob/Gyn  Pediatrician

50-54                76        18        67       29         40
55-59                53        14        26       32         29
60-64                34        14        23       20         20
65-69                50        21        24       18         13
70+                  84        47        36       23         17
Total (all ages)    697       155       725      295        342

Physician
age (yr)          Other  Unknown  Total

50-54               381     0       611
55-59               295     1       450
60-64               223     1       335
65-69               175     1       302
70+                 205    28       440
Total (all ages)  3,041    39     5,294

(a)Ob/Gyn, obstetrics and gynecology. Data from Mississippi State Board
of Medical [Licensure.sup.8a].

Table 2

Selected Mississippi counties: Number of physicians nearing retirement
within 5-10 years (a)

                              No. at or near
              Current no.     retirement age      County
County        of physicians  (in next 5-10 yr)  population

Amite               3                1            13,906
Carroll             1                1             9,967
Franklin            3                2             8,160
Greene              4                3            12,630
Humphreys           3                1            11,214
Itawamba            9                4            21,085
Jefferson           4                3             8,385
Kemper              5                2            10,487
Perry               6                5            12,039
Quitman             4                3             9,780
Scott              13                8            24,911
Smith               4                4            15,431
Tallahatchie        5                3            14,587
Webster             3                3            10,633
Yalobusha           5                4            12,627


              Physician-to-population ratio
County        after these physicians retire

Amite                    1:6,953
Carroll                      N/A
Franklin                 1:8,160
Greene                  1:12,630
Humphreys                1:5,607
Itawamba                 1:4,217
Jefferson                1:8,385
Kemper                    1:3496
Perry                   1:12,039
Quitman                  1:9,780
Scott                    1:4,982
Smith                        N/A
Tallahatchie             1:7,293
Webster                      N/A
Yalobusha               1:12,627

(a)N/A, not applicable because projected number of physicians = 0 Data
from Mississippi State Board of Medical [Licensure.sup.8a].

Accepted March 25, 2002.

References

(1.) Hart-Hester S, Phillips DM. The Status of primary care in rural Mississippi. J Miss State Med Assoc 2000;41:639-646.

(2.) Iglehart JK. Health care reform and graduate medical education. N Engl J Med 1994;330:1167-1171.

(2a.) Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services. Health professional shortage areas. Available at: http://www.bhpr.hrsa.gov/shortage/. Accessed January 16, 2003.

(2b.) Council on Graduate Medical Education. COGME 10th report: Physician distribution and health care challenges in rural and inner-city areas. Rockville, MD, Division of Medicine and Dentistry, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, February 1998. Available at: http://www.cogme.gov/rtpt10.htm. Accessed January 16, 2003.

(3.) U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC, U.S. Department of Health and Human Services, 2000. Available at: http://www.healthypeople.gov/document/. Accessed December 16, 2002.

(4.) Health Resources and Services Administration. State Health Workforce Profiles. Rockville, MD, National Center for Health Workforce Analysis, 2001. Available at: http://www.bhpr.hrsa.gov/healthworkforce/profiles/. Accessed December 16, 2002.

(5.) Forbes RC, Morrison JC, Phillips DM, Replogle WH. Twenty year primary care graduate survey at the University of Mississippi Medical Center. J Miss State Med Assoc 2000;41 :443-445.

(6.) LaRavia D, Calvert J, Zavala J, Smith DO, Talley S, Gingrich D, et al. Keeping Physicians in Rural Practice: American Academy of Family Physicians Rural Recruitment and Retention Position Paper. Leawood, KS, American Academy of Family Physicians. Available at: http://www.aafp.org/rural/ruralrr.pdf. Accessed December 16, 2002.

(7.) Damos J, Christman C, Gjerde C. Using rural training tracks to encourage rural practice careers and enhance training in family medicine. Acad Med 1998;73:599.

(8.) Abererombie SA. Rural residency training tracks recruitment survey. J Rural Health 2000; 16:295-296.

(8a.) Mississippi State Board of Medical Licensure. Available at: http:// www.state.ms.us/frameset.jsp?URL=http://www.msbml.state.ms.us/. Accessed January 16, 2003.

(9.) U.S. Department of Health and Human Services. Chapter 3: The Registered Nurse Population 2000. In: Spratley E, Johnson A, Sochalski J, Fritz M, Spencer W, eds. The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses. Washington, DC, Division of Nursing, Bureau of Health Professions, Health Resources and Service Administration, U.S. Department of Health and Human Services.Availableat:http://bhpr.hrsa.gov/healthworkforce/msurvey/mss 1.htm# Chap3. Accessed December 16, 2002.

(9a.) Mississippi State Department of Health. Mississippi State Health Plan 1999. Jackson, MS. State Department of Health.

(10.) Deleted in proof.

(11.) Mississippi State Board of Medical Licensure. Available at: http://www. state.ms.us/framcset.jsp?URL=http://www.msbml.state.ms.us/. Accessed January 16, 2003.

(11a.) Mississippi Board of Dental Examiners. Available at http://www.state.ms.us/frameset.jsp?URL=http://www.msbde.state.ms.us/ . Accessed January 16, 2003.

(12.) U.S. Public Health Service, Office of the Surgeon General. Oral Health in America: A Report of the Surgeon General. Rockville, MD, U.S. Public Health Service, 2000. Available at: http://www.nidcr.nih.gov/sgr/sgrohwcb/welcome.htm. Accessed December 17, 2002.

(13.) National Institute of Dental and Craniofacial Research, National Institutes of Health. NIDCR News: First-ever Surgeon General's Report on Oral Health Finds Profound Disparities in Nation's Population (press release). Bethesda, MD, National Institutes of Health, May 25, 2000. Available at: http://www.nider.nih.gov/news/052500.htm. Accessed December 17, 2002.

(14.) State of Mississippi. Official State of Mississippi web site: Mental Health. Available at: http://www.mississippi.gov/ms_sub_sub_template.jsp? Category_ID=46. Accessed December 17, 2002.

(15.) Bureau of Mental Health, Mississippi Department of Mental Health. Adult/community services. Available at: http://www.dmh.state.ms.us/ adult_community_mental_health_services.htm. Accessed January 16, 2003.

RELATED ARTICLE: Key Points

* Recruitment and retention of health care professionals for rural settings continues to be a major concern for Mississippi.

* Mostly family medicine physicians and general practitioners serve the more rural counties in Mississippi.

* Twenty-two percent of Mississippi's current nursing workforce is 50 years of age or older.

* Nine of Mississippi's 82 counties have only one dentist each, and 7 counties have no dentists serving the more than 76,000 citizens of those counties.

* Mississippi's health care workforce is not well distributed.

From the Department of Family Medicine, University of Mississippi Medical Center, Jackson, MS.

Reprint requests to Susan Hart-Hester, PhD, Department of Family Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216-4505.

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9602-0149