Statewide primary care service areas (PCSAs) developed by the Office for Family Health, Education & Research (OFHER) are presented in this policy brief, by means of interactive maps using Geographical Information System (GIS) software, and by means of interactive tables.
The U.S. Department of Health and Human Services Health Resources & Services Administration Bureau of Health Workforce Division and Shortage Designation is requiring all State Primary Care Offices to establish Rational Service Area Plans covering their entire state/territory by 2022. States are allowed four years to accomplish this project (2019–2022).
The description of a rational service area was introduced in the State Health planning Act of 1974. Section 332. [254e] (a) (1) of the Public Health Service Act designates Health Professional Shortage Areas as an urban or rural area (which need not conform to the geographic boundaries of a political subdivision and which is a rational service area of the delivery of health care services)
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Federal Register Volume 63 September 1998 in the section Proposed Rules for Designation of Health Professional Shortage Areas (HPSA) and Medically Underserved Areas and Populations (MUA/P) includes a statement that States will be encouraged to define a complete set of rational service areas covering its territory
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A rational service area for primary care, a PCSA, is a relatively self-contained primary care geographic unit that reflects utilization patterns for primary care. In other words, it is an area within which most residents could or do seek and obtain most of their primary health care services.
The purpose of establishing PCSAs is to enhance the ability of states to better identify their primary care health needs and explore ways to meet those needs at functional geographic levels.
There are seven criteria for PCSAs that are commonly specified in federal publications, published articles, and reviewed in detail in the 2000 Bureau of Primary Health Care Report:
The Office of Family Health Education & Research developed a set of 79 non-overlapping PCSAs that cover Alabama. These PCSAs are based on population centers that are 30 minutes or more driving time to other population centers. These population centers and /or general admission hospitals (GAHs) serve as centroids. Each PCSA consists of the region of the state that is closer to that centroid than any other, as measured by the road network.
Using PCSAs instead of counties, ZIP codes, and/or Rural-Urban Commuting Area (RUCA) codes leads to databases that are based on non-restricted, non-artificial, but geographically limited populations with identifiable demographics. PCSAs allow the ability to identify and measure the primary care needs of populations in geographical areas in term of accesible healthcare resources and assets. In our case, Alabama PCSAs allow us to measure a defined population's accessibility to designated population centers where PCPs and GAHs are located and to estimate local PCP shortages or oversupply.
Our PCSAs rural/urban designations use the Centers for Medicare & Medicaid Services definition of rural based on the National Census Bureau urban-centric concept.
Alabama's PCSAs when used to define Health Professional Shortage Areas produce accurate data for linking PCP availability to population demand, HIPSA standard or PCP population ratio. Using PCSAs is a functional alternative to designating partial counties as rural or urban. It eliminates the necessity of trying to determine the rurality of a political subdivision.
The use of PCSAs provides a foundation from which to build on our current primary care coverage and to pursue more in-depth analysis of workforce issues and barriers to primary care access based on the rationally determined micro-populations at individual sites. This model gives the definition and focus for developing public and private partnerships, rural public policy, legislative support, pilot projects, and rural outcome research.
In this report, a primary care physician is as non-federal allopathic (MD) or osteopathic (DO) physician, who holds an unrestricted license to practice medicine in the state of Alabama, is providing direct patient care and practices principally in one of the five primary care specialties—general medicine, family medicine, general internal medicine and pediatrics and Med-Peds. Since the foot print of Med-Peds licensed physicians is so small they are counted with family physicians. PCPs engaged solely in administration, emergency medicine, emergency/urgent Care, research, sports medicine, teaching, telemedicine, or are hospitalist, retired physicians who hold unrestricted licenses, federal physicians (VA physicians) and federal and state prison physicians are not counted.
A 40 hour work week is used as the standard for counting a PCP as a 1.0 FTE/PCP. Each PCP reporting direct patient care for 40 hours or more per week are counted as 1.0 FTE. Those PCPs who are not available for direct patient care to residents in their area for 40 hours per week, have their FTE figure determined by the counting a 0.1 FTE for each 4 hours or 1/2 day that they are available. PCP data presented as FTE/PCP, such as the number of PCPs located in each PCSA are tallied by determining the FTE of each PCP in a given PCSA. Any physician data not identified as FTE physician data considers each physician as 1.0 FTE.
In addition the following adjustments were made to the PCP count: Those residents in training with significant direct patient care time in an ambulatory setting were counted as 0.1 FTE/PCP. Faculty with significant practice and teaching time in an ambulatory setting were counted at 0.5 FTE/PCP.
A rational service area is a relatively self-contained geographic area that reflects utilization patterns for primary care. More simply stated, it is an area within which most residents could or do seek to obtain direct patient access to a PCP(s). Each PCSA includes a population center. Alabama has 79 population centers where in 2019 97.8% of Alabama’s PCPs practice sites are located. Each PCSA population center historically has had the ability to recruit PCPs. These population centers are spatially located such that 96% of Alabama’s 4,850,771 residents have 30 minute of less travel time access to PCPs.
The 79 PCSA population centers (the geographic locations where most residents in a PCSA catchment area could or do seek to obtain direct patient access to a PCP) are designated rural or urban using the Centers for Medicare and Medicaid Services (CMS) definition of rural. A rural area is an area that is not delineated as an urbanized area by the Bureau of the Census. This definition is used by CMS to assess if a rural health clinic’s location meets their requirement of being located in a rural area.
CMS defines a urbanized areas as central cities of 50,000 inhabitants or more or cities with at least 25,000 inhabitants which, together with contiguous areas having stipulated population density, have combined populations of 50,000 and constitute, for general economic and social purposes, single communities and closely settled territories surrounding cities and specifically designated by the Census Bureau as urban.
A rural population center is a city, town or community not located within an urbanized area where rural residents do or could access PCPs and because of topography, market or transportation patterns, distinctive population characteristics or other factors, has limited access to contiguous population centers as measured generally by a travel time of greater than 30 minutes to such population centers.
Established neighborhoods and communities within urbanized areas where residents generally located within 30 minutes of less do or could seek access to PCPs and which display a strong self-identity (as indicated by a homogeneous socioeconomic or demographic structure and/or a tradition of interaction or interdependency), have limited interaction with contiguous populations centers and which have a minimum population of 20,000. Urban catchment areas do not recognize urbanized area boundaries.
Population count is the total permanent resident civilian population within the catchment area of the PCSA, excluding inmates of institutions.
The ratio of the number of PCSA residents to a PCP is calculated using the FTE/PCP count.
The number of PCP/FTEs needed to serve a given PCSA is determined by comparing the average number of PCP vists per year needed by the population with the average number of patient visits that a PCP can provide. A more detailed explanation is given in the data table page.
Based on physician self-reporting, the Alabama Board of Medical Examiner’s Alabama license renewal applications database documents that Alabama has a total of 12,513 licensed physicians. 2,385 identify as primary care physicians (19.1%) and 10,128 (80.9%) Identify as specialists. Alabama’s physician workforce consists of 11,400 (91.1%) allopathic physicians and 713 (5.7%) osteopathic physicians. 18.2% (2074/11,400) of allopathic physicians identify as PCPs. 24.0 % (171/713) Osteopathic physicians identify as PCPs. Female physicians account for 28.8% (3,599/8,803) of Alabama’s total physician workforce, but they represent almost 40% of the PCP workforce (901/1,466).
The metrics used to describe the 2019 PCP workforce are; the spatial location of PCPs in the state, the population that they serve, the designation of the population as rural or urban, the number of FTE PCPs at a location, PCPs who are 65 years or older, the total number of FTE PCPS per location, the population to PCP ratio at a location, the current need or shortage of FTE PCPs at a location. Using these metrics the status of Alabama’s PCP workforce was analyzed for each of 79 population centers.
Alabama as a whole has 2,074 verified FTE PCPs of which 1,239 are Family physicians, 664 are general internists and 470 are general pediatricians. 431 of these PCPs are 65 years of age or older. Alabama needs 1,725.3 FTE PCPs to meet the population demand for primary care for Alabama’s 4,850,771 residents. 18 population centers are designated as urban, while 61 are designated as rural. 41 population centers have a shortage of PCPs. 37 of these are rural population centers. 38 population centers have adequate PCPs or a surplus of PCPs and 24 are rural. The 41 population centers with a need for additional PCPs need 131 additional PCPs to eliminate the PCP shortage for the state as a whole, but these PCP must be located in specific population centers.
The Office for Family Health Education and Research provides an infrastructure where opportunities for research in education, policy, clinical medicine and other scholarly works in primary care can flourish. The office produces and disseminates practical clinical information to primary care physicians, coordinates and conducts studies that deal with the health care education of primary care physicians and patients, as well as the broader issues of state health policy, health access and health manpower.