Based on their extensive training, physicians are positioned as leaders within the health system. Therefore, information on the supply and distribution of Indiana’s physician workforce is critical to informing any health workforce policy or planning efforts. This fact sheet presents key information on Indiana's physician workforce, including excerpts on primary care physicians and psychiatrists

Randolph, C., Norwood, C., Maxey, H.

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Physician Workforce Fact Sheet     2016IntroductionIt is important to fully understand the characteristics of the physician workforce as they serve as the backbone of the system.  Supply data on the physician workforce are routinely collected through surveys administered by the Indiana Professional Licensing Agency (IPLA) in conjunction with biennial license renewals.1  In 2015, 26,536 physicians renewed their license to practice medicine in the state of Indiana of which only 10,057 physicians reported providing direct patient care. Over one-third (37%) reported primary care as their specialty (figure 1).2  Primary care physicians (PCP) in other industrialized nations make up approximately 50% of the physician workforce.3   Comparatively, only 35% of the U.S. physician workforce practices in a primary care specialty.458%37%4%1%Figure 1: Physician Specialty Breakdown, 2015All Other SpecialtiesPrimary Care SpecialtiesPsychiatryNon-RespondentsVulnerable populations frequently struggle with access to services and rely heavily on a robust safety net comprised of PCPs who offer sliding fee scales (payment schedule based on ability to pay) and accept Medicaid or other public health insurance programs. Roughly 50% of Indiana PCPs report not offering a sliding fee scale and 10.3% report not accepting Medicaid.Table 1: Patient Population, Primary Practice Location Sliding Fee Scale Patient Population,   Primary Practice LocationPrimary Care (%)Psychiatrist (%)All Physicians (%)I do not offer a sliding fee scale 49.8 48.8 52.7Sliding fee patients account for 0% - 50% of my practice 41.0 44.5 34.5Sliding fee patients account for great-er than 50% of my practice 1.5 6.7 1.6    Non-Respondents 7.7 7.4 11.2 Total 100.0 100.0 100.0 Medicaid Patient Population,   Primary Practice LocationI do not accept Indiana Medicaid 10.3 20.1 8.5Indiana Medicaid account for 0% - 50% of my practice72.0 51.3 73.8Indiana Medicaid account for  greater than 50% of my practice13.2 28.7 10.7    Non-Respondents 4.5 4.7 7.0 Total 100.0 100.0 100.0Source: Indiana Physician Re-Licensure Survey, 2015 Notes:  Data on sliding fee scale and Medicaid patient populations  were not provided by every re-spondent.  Not every respondent had a primary practice address in Indiana, but may have a secondary practice address in Indiana. These practitioners are excluded from this table.1 See Data Report: 2016 Physician Licensure Survey for full inclusion/exclusion criteria and survey methodology. http://hdl.handle.net/1805/96532 Primary care specialties, as defined by HRSA, include family medicine, general practice, general internal medicine, general pediatrics, and obstetrics & gynecology.3 Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly. 2005;83(3):457-502.4 Bodenheimer T, Chen E, Bennett HD. Confronting the Growing Burden of Chronic Disease: Can the U.S. Health Care Workforce Do theJob? Health Aff (Millwood). 2009;28(1):64-74.Core Safety Net ProvidersWho Are They?Core safety net providers deliver a significant level of healthcare to unin-sured, Medicaid, and other vulner-able patients. The “Core Safety Net Providers” exhibit two distinguishing characteristics:1. Either by legal mandate or explicitly adopted mission, they offer care to patients regardless of their ability to pay for those services; and 2. A substantial share of their patient mix are uninsured, Medicaid, and other vulnerable patients.Core safety net providers typically include public hospitals, community health centers, and local health de-partments, as well as special service providers such as AIDS and school-based clinics.  In some communities, teaching and community hospitals, private physicians, and ambulatory care sites fill the role of core safety net providers.Source:  Adopted from the Institute of Medicine’s report, “America’s Health Care Safety Net: Intact but Endangered." Physician Workforce Fact Sheet     2016Primary Care Physicians“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”5   Furthermore, the links between primary access, health outcomes, and costs are well documented, which makes ensuring a strong primary system across the state of Indiana crucial to securing the health of Hoosiers and improving the efficiency of Indiana’s health system.6   Fewer medical graduates are choosing primary care specialties due in large part due to growing clinical responsibility in conjunction with declining salaries.7  This trend exemplifies the importance of initiatives to recruit and retain primary care providers.  One of the largest predictors of physician recruitment and retention is the location in which they completed their graduate medical education (GME) training.  Unfortunately, less than 50% of the PCP in Indiana report completing their residency within the state. Therefore, policy initiatives have strived to increase capacity for GME while also looking to improve retention of Indiana medical residents. 46% 29% 14% 11% Figure 2: Primary Care Specialty Breakdown, 2015  Family Medicine/General Practice Internal Medicine (General) Pediatrics (General) Obstetrics and Gynecology 46%The number of IndianaPCPs who report family medicine general practice  as their principal specialty.5 Nagykaldi Z, Mold JW, Robinson A, Niebauer L, Ford A. Practice Facilitators and Practice-based Research Networks. J Am Board Fam Med. 2006;19(5):506-10.6 Maxey H, Norwood C, Sheff Z, Walters S, Indiana Primary Health Care: Description, Distribution, Challenges, & Strategic Recommendation to Empowered Decision Making.   Indiana University Center for Health Policy, 2012.7 Bodenheimer T, Berenson RA, Rudolf P. The Primary Care-Specialty Income Gap: Why it Matters. Ann Intern Med. 2007;146(4):301-6.Table 2: Primary Care Physician Education Information  Education/Training Characteristics Medical School (%) Residency (%)   Indiana 39.4 48.8   Contiguous states 19.5 24.9   Other US states 19.0 23.9   Another country 21.3 1.1   Non-Respondents 0.9 1.3 Totals 100.0 100.0Source: Indiana Physician Re-Licensure Survey, 2015 Notes:  Contiguous states include Illinois, Kentucky, Michigan and Ohio.Physician Workforce Fact Sheet     2016Primary Care Physicians: DemographicsIndiana’s primary care physician workforce is primarily comprised of non-Hispanic (96.1%) and White (74.6%) professionals.  A complete breakdown of race/ethnicity as well as other key demographics is provided in table 1.  Figure 3 compares the racial and ethnic characteristics of the primary care physician workforce against the Indiana residential population to identify gaps in workforce diversity.It is not necessary that providers and patients be of the same demographic for successful healthcare delivery; however, greater levels of diversity are linked to advancing cultural competency, increasing access to high-quality healthcare services, and optimal management of the health system.⁸  Strategies for cultivating a more racially and ethnically diverse workforce reflecting the demographics of Indiana’s population should be considered and integrated into any health workforce policy discussions.White Black or African AmericanAsian Hispanic or Latino86.0%9.6%2.1%6.7%75.0%6.3%12.9%3.1%Figure 3: Dierence Between Primary Care Physician Diversity and Indiana Population Diversity, 2015Indiana Population Primary Care Physician  8 Cohen JJ, Gabriel BA, Terrell C. The Case for Diversity in the Health Care Workforce. Health Affairs. 2002;21(5):90-102.Table 3: Primary Care Physician Demographic CharacteristicsFemale Male Non-Respondents Total Mean Age 45.5 52.6 53.0 50.3Age Groups N % N % N % N %Under 35 261 17.6 226 10.5 9 6.8 496 13.235-44 562 38.0 451 20.9 28 21.1 1,041 27.645-54 381 25.8 555 25.7 35 26.3 971 25.855-64 226 15.3 577 26.8 43 32.3 846 22.5Over 65 49 3.3 347 16.1 18 13.5 414 11.0Non-Respondents 0 0.0 0 0.0 0 0.0 0 0.0Total 1,479 100.0 2,156 100.0 133 100.0 3,768 100.0EthnicityHispanic or Latino 61 1.7 52 1.4 0 3.1 113 3.1Not Hispanic or Latino 1,408 38.5 2,086 57.6 131 96.1 3,625 96.1Non-Respondents 10 0.3 18 0.5 2 0.8 30 0.8Total 1,479 40.4 2,156 59.6 133 100.0 3,768 100.0RaceWhite 1,064 71.9 1,625 75.4 86 64.7 2,775 73.6Asian 195 13.2 262 12.2 25 18.8 482 12.8Other 91 6.2 143 6.6 11 8.3 245 6.5Black 115 7.8 102 4.7 10 7.5 227 6.0Native Hawaiian/Pacific Islander 0 0.0 3 0.1 0 0.0 3 0.1American Indian or Alaska Native 4 0.3 4 0.2 0 0.0 8 0.2Non-Respondents 10 0.7 17 0.8 1 0.8 28 0.7Total 1,479 100.0 2,156 100.0 133 100.0 3,768 100.0Source: Indiana Physician Re-Licensure Survey, 2015 Notes: Data on Gender was not provided for every respondent by Indiana Professional Licensing Agency (IPLA). Age was cal-culated by measuring the difference between the survey date and the respondent’s date of birth provided by IPLA.Physician Workforce Fact Sheet     2016Physician Supply and DistributionRural communities are frequently faced with insufficient resources to ensure the health, quality of life and economic prosperity for their residents.   One important resource commonly scarce in rural communities is the health workforce. Map 1 demonstrates the distribution of the primary care physician workforce in rural Indiana based on physician full-time equivalent (FTE) to population ratio. Darker counties illustrate areas with more Indiana residents per one physician FTE and thus present potential problems for access to care, especially for vulnerable and underserved populations in these regions.Indiana CountiesPrimary Care Physicians:Population to Provider FTE Ratio539.9 - 3,500.93,501.0 - 7,450.07,450.1 - 15,209.515,209.6 - 30,247.0No FTE ReportedRural Counties±Source: Indiana Physician Re-Licensure Survey, 2015; US Census Bureau, ACS 5-year population estimates, 20151,331:1The ratio of Indiana  residents per physician in rural communities.566:1The ratio of Indiana  residents per physician in urban communities.Map 1: Population to Primary Care Physician FTE RatioPhysician Workforce Fact Sheet     2016Recruitment and RetentionNot only does Indiana have relatively few psychiatrists practicing in Indiana, but recruitment and retention of psychiatric residents remains low.  Location of residency training is a strong predictor of retention post training.  In 2015, only 34.1% of physicians practicing in Indiana reported completing their residency in the state. Psychiatric Workforce Shortages and DistributionIn addition to a relatively small psychiatric workforce, a mal-distribution of practicing psychiatrists throughout Indiana poses an additional threat to access to care for Indiana residents. In 2012, 43 Indiana counties had no practicing psychiatrist.9   In 2012, approximately 40% of Indiana counties meeting one or more criterion for Mental Health Professional Shortage Area (MHPSA) designation did not currently hold this federal designation.   Obtaining a federal designation for a particular geographic region or special population increases access to resources, including federal programs that incentivize health professionals to work in these underserved locations.Mental HealthProfessional Shortage AreasThere are approximately 40 Mental Health Professional Shortage Areas (MHPSA) in Indiana. MHPSAs are based on a psychiatrist to population ratio of 1:30,000.  In other words, when there are 30,000 or more people per psychiatrist, an area is eligible for MHPSA designation. Applying this formula, it would take approximately 2,800 additional psychiatrists in Indiana to eliminate the current mental health provider shortage.Between 2007 and 2015, Indiana has averaged 420 actively practicing psychiatrists. Although the number of practicing psychiatrists in Indiana has declined since 2009, 2015 offered slight increase. Additional supply information on the psychiatric workforce may be found in the 2016 Physician Licensure Survey Data Report. Lack of growth and aging in the psychiatric workforce raises concerns and may have serious implications on mental in Indiana in the next decade.2007 2009 2011 2013 2015 420 484 440 356 403 Figure 4: Active Indiana Psychiatrists  Active Indiana Psychiatrists Psychiatrists Supply The psychiatric workforce, which serves as a critical component of Indiana’s mental health system, is shrinking and aging. Recruiting new physicians into psychiatry will require close examination of pertinent education policy, such as institutional and funding priorities.9 See the “Policy Report: 2012 Indiana Mental Health Workforce” for additional information on mental health professional shortages areas and    psychiatric workforce shortages in Indiana. http://hdl.handle.net/1805/5435Table 4: Psychiatry Education Information  Education/Training   CharacteristicsMedical School (%)Residency (%)   Indiana 33.3 34.0   Contiguous states 19.4 25.0   Other US states 18.6 39.0   Another Country 28.0 1.0   Non-Respondents 0.7 1.0 Total 100.0 100.0Source: Indiana Physician Re-Licensure Survey, 2015  Notes: Contiguous States include Illinois, Kentucky, Michigan, and Ohio.Physician Workforce Fact Sheet     2016Estimating Health Workforce CapacityPolicymakers have struggled with accurately projecting the capacity of the health system to deliver patient care.  Yet this data is imperative for evidence-based health policy development aimed to improve access to health.  States have looked to partnerships with state licensing agencies to collect potentially rich data on the “size, skill mix, and competencies of today’s health workforce relative to anticipated future workforce needs.”10 These data collected through the licensure process provide valuable information which may allow policy makers to better understand the health workforce and develop evidence-based health workforce policies. While the traditional method of “counting heads“of licensed physicians may seem appropriate, this approach may lead to potential overestimates of the workforce capacity to provide health services.  As many providers may not work full time in patient care or in health care all together, yet retain a license to practice, a basic head count does not allow for accurate distribution information. Workforce capacity is more accurately assessed using the reported FTE working in patient care activities. Figure 5 demonstrates how a head count of licensed physicians in Indiana may lead to overestimating the actual reported capacity by approximately 321%. This example highlights the value of gathering high resolution supply information from health professionals on a routine basis in order to supplement licensure data for accurate projections of the supply and capacity of the health system.26,536 8,256 18,280 0 5,000 10,000 15,000 20,000 25,000 30,000 Head Count (Licensure Data) FTE (Survey Data) Number of PCPs  Delivering Patient Care Figure 5: Potential Overestime of Health Workforce Capacity:  Licensure Data vs. Survey Data Estimated Capacity Potential Overestimate 9See the “Policy Report: 2012 Indiana Mental Health Workforce” for additional information on mental health professional shortages areas and psychiatric workforce    shortages in Indiana. http://hdl.handle.net/1805/5435.10Gaul, K., Moore, J., & Fraher, E. (2016). Collaborating With Licensing Bodies in Support of Health Workforce Data Collection: Issues and Strategies. Health Workforce    Technical Assistance Center. Rensselaer, NY."1110 W. Michigan Street, LO 200Indianapolis, IN 46202-5100

Physician Workforce Fact Sheet

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Physician Workforce Fact Sheet

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