Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington.
OBJECTIVE
Little is known about whether different types of physician and nonphysician primary care clinicians vary in their propensity to care for underserved populations. The objective of this study was to compare the geographic distribution and patient populations of physician and nonphysician primary care clinicians.


METHODS
This study was a cross-sectional analysis of 1998 administrative and survey data on primary care clinicians (family physicians, general internists, general pediatricians, nurse practitioners, physician assistants, and certified nurse-midwives) in California and Washington. For geographic analysis, main outcome measures were practice in a rural area, a vulnerable population area (communities with high proportions of minorities or low-income residents), or a health professions shortage area (HPSA). For patient population analysis, outcomes were the proportions of Medicaid, uninsured, and minority patients in the practice.


RESULTS
Physician assistants ranked first or second in each state in the proportion of their members practicing in rural areas and HPSAs, and in California physician assistants also had the greatest proportion of their members working in vulnerable populations areas (P < .001). Compared with primary care physicians overall, nurse practitioners and certified nurse-midwives also tended to have a greater proportion of their members in rural areas and HPSAs (P < .001). Family physicians were much more likely than other primary care physicians to work in rural areas and HPSAs (P < .001). Compared with physicians, nonphysician clinicians in California had a substantially greater proportion of Medicaid, uninsured, and minority patients (P < .001).


CONCLUSIONS
Nonphysician primary care clinicians and family physicians have a greater propensity to care for underserved populations than do primary care physicians in other specialties. Achieving a more equitable pattern of service to needy populations will require ongoing, active commitment by policy makers, educational institutions, and the professions to a mission of public service and to incentives that support and promote care to the underserved.
Grumbach
Kevin
K
Center for California Health Workforce Studies, University of California, San Francisco, Calif, USA. keving@itsa.ucsf.edu
Hart
L Gary
LG
Mertz
Elizabeth
E
Coffman
Janet
J
Palazzo
Lorella
L
D000328:Adult; D001291:Attitude of Health Personnel; D002140:California; D003430:Cross-Sectional Studies; D005260:Female; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008507:Medically Underserved Area; D008875:Middle Aged; D010821:Physicians, Family / Q000706:statistics & numerical data; D011361:Professional Competence; D011365:Professional Practice Location / Q000706:statistics & numerical data; D012423:Rural Health; D014504:Urban Health; D014861:Washington