La. Admin. Code tit. 48 § I-11903

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-11903 - Physicians

A. Introduction

1. In the late 1960's, a study was published by the Carnegie Institute which identified and forecast a large manpower shortage in the United States in the area of supply of physicians. Throughout the 1970's, a disproportionately large number of students entered medical training schools. It is now thought by many experts that most of the forecast shortages have been prevented. The preliminary indications are that many previously identified shortages of physicians are being met in Louisiana and other forecast shortages allayed by a significant influx of physicians into the health care manpower supply. There are only a few exceptions to this generally healthy status of physician manpower in Louisiana.

B. Supply

1. The most recent data available indicates that Louisiana does not have any serious problems in terms of physician supply in making comparisons with the rest of the nation. According to figures released by the United States House of Representatives Sub-Committee on Health and Environment, the current national physician to population ratio is 165.3 per 100,000 general population. Similar figures for Louisiana indicate that its physician supply is 136.1 physicians per 100,000 general population. Louisiana compares favorably with other states in the region. The following table indicates the physician per 100,000 ratio for the United States and for those states in the southern region.

Number of Physicians in Patient Care	Number of Physicians per 100,000
United States	218,497	165.3
Louisiana	5,436	136.1
Alabama	4,297	114.7
Kentucky	4,331	124
Mississippi	2,455	102.9
Tennessee	6,131	140.6
Arkansas	2,419	111.5
Oklahoma	3,489	121.9
Texas	18,406	139.0

2. A critical aspect of physician supply is the number of physicians available who practice in the various medical specialties and sub-specialties. The Louisiana Council on Physician Manpower has provided an analysis of physician manpower supply broken down according to the various specialties, with comparison to "ideal" practitioner to population ratios developed by the Graduate Medical Examiners National Advisory Committee (GMENAC). The ideal supply ratios developed by the GMENAC are based on health care utilization patterns in the U.S. population as a whole, and take into consideration the number of physicians who may be expected to participate in active patient care, attrition and expected additions to supply.

3. The analysis by the Louisiana Council on Physician Manpower is presented in Table 11.1. Physician specialty areas are separated into four basic categories:

(a) those specialties in which Louisiana has achieved or surpassed the GMENAC standard;

(b) those specialties in which Louisiana has not surpassed the GMENAC standard, but in which the state is likely to achieve and possibly surpass that standard with continuation of its present rate of manpower production;

(c) those specialties in which Louisiana is short, but only in proportion to its overall shortage of physicians and in which production capacity (i.e., residency training positions) is sufficient to allay future shortage; and

(d) those specialties in which the ratio of physicians in Louisiana is significantly higher than the ideal ratio and also significantly higher than the ratio for physicians in general. For this latter category, the Council recommends study and initiatives directed toward alleviating residency shortages, or problems with recruitment or problems within the specialty itself. There are a number of specialties not addressed in Table 11.1, primarily because of these specialty areas being so small as to make difficult the determination of "adequate supply". Clearly the specialties in category (d) warrant most attention. In this category are most of the primary care physicians (pediatrics, general practice, family practice, and general internal medicine) whose accessibility is a vital component of an effective health care system. Also in this category are psychiatry and anesthesiology, specialties whose distribution and availability are critical to local health system functioning.

Table 11.1 Louisiana, U.S. and GMENAC* Ratios of Physicians per 100,000 Population, by Specialty, 1979
Specialty	LA Ratio	US Ratio	GMENAC Recommended Ratio	No M.D.'s Needed in LA to Reach GMENAC Ratio
(a). General and C/R Surgery	11.2	11.4	9.7	-60
Neurosurgery	1.2	1.2	1.1	-4
Opthalmology	5.0	4.9	4.8	-8
(b). Ob-Gyn	9.6	9.2	9.9	+12
Urology	3.0	2.9	3.2	+8
Plastic Surgery	1.0	1.1	1.1	+4
(c). Otoloryngology	2.8	2.5	3.3	+20
Radiology	6.0	7.4	7.4	+56
Pathology	4.4	4.7	5.5	+44
Orthopedic Surgery	4.9	5.0	6.2	+52
IM Cardiology	2.5	3.8	3.2	+28
IM Allergy	0.6	0.7	0.8	+8
Ped. Allergy	0.3	0.2	0.4	+4
Thoracic Surgery	0.6	0.8	0.8	+8
IM Pulmonary Dis.	1.1	1.3	1.5	+16
Dermatology	2.0	2.1	2.9	+36
(d). General Pediatrics	7.7	9.1	12.4	+188
GP/Fam. Prac.	19.6	22.6	34.5	+596
Preventive Med.	1.6	2.3	3.0	+56
Neurology	1.2	1.8	2.3	+44
Gen. Int. Med.	14.7	21.1	28.9	+568
Ped. Cardiology	0.2	0.3	0.4	+8
IM Gastroenterology	1.0	1.5	2.0	+40
Anesthesiology	3.6	6.0	8.6	+200
Gen. Psychiatry	6.3	9.9	15.8	+380
Phys. Med. & Rehab.	0.3	0.7	1.3	+40
Child Psychiatry	0.7	1.3	3.7	+120

*Graduate Medical Examiners National Advisory Committee

4. A spokesperson for the Louisiana Council on Physician Manpower has indicated that the residency channels for many of the specialties in category (d) are operating at full or nearly full capacity, although psychiatry and the primary care specialties are not attracting sufficient residents. Psychiatry and primary care are specialty areas which have been identified nationally as having health care manpower shortage problems. Shortages exist in Louisiana as a whole in these specialty areas, but are depicted more meaningfully in an analysis of local distribution problems.

C. Distribution

1. In spite of the relatively adequate supply of physicians overall in Louisiana, there are areas of the state which suffer serious shortages. The National Health Planning Guidelines published in the Federal Register of November 17, 1980 indicate that an appropriate primary care physician to population ratio is 1/3500. The standard is reduced to 1/3000 if conditions of high need are established. The criteria to establish high need are (a) the area has more than 100 births per year per 1000 women aged 15-44; (b) the area has more than 20 infant deaths per 1000 live births; and (c) more than 20% of the population has an income below the poverty level. Almost every area of Louisiana meets the definition of high need because of high infant mortality and poverty levels. Therefore, the standard of 1/3000 can be used to evaluate the adequacy of primary care physicians in Louisiana.

2. Table 11.2 depicts those parishes and population areas in the state and health system areas where a manpower shortage has been designated for primary care physicians. One of the eleven parishes in the New Orleans/Bayou-River health system area is a designated shortage area, with five population pockets also identified as shortage areas. In Mid-Louisiana, eleven of the 24 parishes are designated shortage areas, with an additional four population areas also targeted. In North Louisiana, 13 of the 29 parishes are designated shortage areas, with four additional sites named as shortage areas. Thus it can be seen that 25 of the state's 64 parishes and eleven other sites do not have sufficient primary care physicians to provide health care services to the local population. The critical issue in primary care physician manpower at this time is distribution. A significant portion of the state's population does not have adequate accessibility to primary care physician services because of the maldistribution of available physicians.

Table 11.2 Primary Medical Care Designated Manpower Shortage Areas - 1980
Area		PC PHSY. FTE	POP. EST. (00s)		Priority Level*
New Orleans/Bayou-River
Assumption Parish		5.0	205		2
Dulac		0.0	94		1
Desire/Florida (N.0.)		5.0	367		1
Teche		8.4	412		2
Lafitte		1.0	187		2
Northeastern St. Tammany		0.0	137		1
Mid-Louisiana
Ascension Parish	1.0		40		3
Cameron Parish	1.0		42		3
East Feliciana Parish	1.0		74		1
Evangeline Parish	10.0		318		3
Iberville Parish	1.0		30		4
Jefferson Davis Parish	1.0		32		4
Livingston Parish	3.0		365		2
Pointe Coupee Parish	3.5		250		1
St. Helena Parish	2.0		93		3
West Baton Rouge Parish	2.0		202		1
West Feliciana Parish	2.0		113		3
St. Martin	0.0		N/A		2
Eden Park (B.R.)	2.0		230		1
Merryville	1.0		41		3
North Lake Charles	1.0		231		1
North Louisiana
Bienville Parish	3.0		160	1
Bossier Parish	3.0		645	1
Caldwell Parish	3.0		102	4
Catahoula Parish	3.0		114	3
DeSoto Parish	4.0		227	1
Grant Parish	2.0		136	1
Jackson Parish	5.0		168	4
Madison Parish	3.0		144	2
Tensas Parish	2.5		84	4
Vernon Parish	5.0		537	1
Webster Parish	1.0		401	2
West Carroll Parish	2.0		130	1
Winn Parish	5.1		164	4
Zwolle	0.0		66	1
West Union	1.0		59	2
Shreveport-Low-Income	0.0		86	1
E. A. Conway Hospital	0.0		N/A	4

* Priority levels are established by the federal Department of Health and Human Services.

3. The problem of bringing primary health care to rural area populations and other population groups who do not have access is one which has been given considerable attention at a national level. The recently de-funded National Health Service Corps placed 11 physicians in partially subsidized practices in several designated shortage areas in Louisiana since 1978. There are also three Rural Health Initiatives in operation in Louisiana, whose goal is to bring primary health care services to the rural population. RHI clinics operate in Tensas Parish, Madison Parish and Catahoula Parish.

4. Parishes with designated shortages of psychiatrists are: Lafourche and Terrebonne in the New Orleans/Bayou-River area; St. Mary in Mid-Louisiana; and in North Louisiana, Caldwell, East Carroll, Franklin, Madison, Morehouse, Ouachita, Richland, Tensas, and West Carroll parishes.

D. Utilization

1. Another problem area in physician manpower is in utilization. A large percentage of the state's physicians practice in areas which are not accessible to the general public. For example, although 80.4 percent of the state's physicians are involved in patient care, roughly half of that number are either involved in surgical specialties (22.3 percent) or in hospital-based practices (19.4 percent). Only 25.5 percent of the state's physicians are involved in General Practice or Medical Specialties. The table below provides a breakdown of how the state's physician supply is distributed among various practice settings.

Type of Practice	Number of Physicians	Percentage of Total
General Practice	731	11.4%
Medical Specialties	901	14.1%
Surgical Specialties	1426	22.3%
Other Specialties	828	13.0%
Hospital-Based	1239	19.4%
Other Activity	440	6.9%
Inactive	410	6.4%
Not Classified	392	6.1%
Total	6367	99.6%

3. The utilization of physicians is important in analyzing manpower need since an area may have significantly fewer physicians available to provide patient care than are counted as being active in the area. This is true particularly in an area such as New Orleans, where a large number of physicians are on staff at medical centers and teaching hospitals and devote only a minor amount of their time to the care of patients from the service area.

E. Resource Renewal

1. In terms of renewing the supply of physicians, Louisiana is slightly ahead of the rest of the nation. Between 1975 and 1979, Louisiana's physician supply grew at a rate of 18.5 percent. The rate for the nation in that time period was 12.8 percent. A spokesperson for the Louisiana Council on Physician Manpower has noted that increased enrollment at the Louisiana State Medical School in New Orleans and at the new school in Shreveport will begin to impact physician supply in about 1982. It takes approximately 7-9 years for the creation of new medical school placements to have an impact on the market supply of physicians. Because the full impact of these expansion programs is yet unknown, the next two to three years will be important ones for assessing any changes brought about by the new placements and for developing other initiatives as needed to address any problems with physician supply and distribution which persist.

F. Resource Goals

1. A supply of physicians actively practicing in the state which meet the suggested ideal practitioner to population ratio by specialty recommended by GMENAC. Improvements specifically are needed in the overall supply of physicians specializing in general pediatrics, general practice, family practice, preventive medicine, neurology, general internal medicine, pediatric cardiology, IM gastroenterology, anesthesiology, general psychiatry, physical medicine and child psychiatry.

2. Development of initiatives to improve the accessibility of primary care physician services in designated shortage areas.

3. Development of initiatives to improve the accessibility of psychiatrists in designated shortage areas.

La. Admin. Code tit. 48, § I-11903

Promulgated by the Department of Health and Human Resources, Office of Management and Finance, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with P.L. 93-641 as amended by P.L. 96-79, and R.S. 36:256(b).