The Journal of Science and Business Research

A Comparison of Physician Density in Three Types

of Health Care Markets in Montana

Sam J. Allen, MBA

Introduction

In an earlier article, we described the apparent relationship between the number of providers (physician, nurse practitioner, and/or physician assistant) in a rural community, and the profitability of that community’s healthcare organization. Although the relationship was far from perfect, we suggested that a relationship exists, none-the-less.

Extrapolating from that train of thought, we have also investigated the physician density of five “metropolitan” areas of Montana, and compared that to the physician density of the rural counties that surround them. Additionally, two rural areas of Montana in which there are no “metropolitan” centers, were considered.

For the purpose of this study, the term “metropolitan” means a city or county with a population center of at least 30,000 persons. In two instances, where the demographics / geography demanded such, the “metropolitan” area was defined as two or more contiguous counties. In the other three instances, “metropolitan” was a single county. The rural area that accompanies each metropolitan area consists of the rural counties surrounding the metropolitan county and contiguous with it, or with another county in that rural grouping.

Findings and Implications

Metropolitan Montana is fortunate, in that health care services are both relatively close-by (convenient) and abundant (indicating the presence of specialists.) These metropolitan average 341 physicians (range 69 – 614), demonstrating an average of 2.62 physicians per 1,000 population (range 2.08 – 3.50.) As expected, the rural areas contiguous with these metropolitan areas have far fewer physicians, averaging only 46 (range 28 – 91) and fewer physicians per 1,000 population, averaging 1.09 (range 0.73 – 1.48.) Although some of the physicians in these rural areas are specialists, many, indeed most, are not. The table below demonstrates the various averages.

Area	# Docs	Docs/1000 Population	Docs/1000 Square miles
Metro Missoula/Kalispell	614	2.48	53.00
Rural Missoula/Kalispell	91	1.16	3.78
Disparity Ratio	6.75	2.14	14.02

Metro Helena/Great Falls	377	2.74	61.21
Rural Helena/Great Falls	28	0.73	1.78
Disparity Ratio	13.46	3.75	34.39

Metro Butte	69	2.08	96.10
Rural Butte	28	1.48	4.60
Disparity Ratio	1.30	1.41	20.89

Metro Bozeman	174	2.30	29.02
Rural Bozeman	46	1.14	3.96
Disparity Ratio	3.78	2.02	9.85

Metro Billings	471	3.50	178.75
Rural Billings	36	0.93	2.72
Disparity Ratio	13.46	3.76	65.72

Rural Eastern Montana	75	1.03	1.79

Rural Northern Montana	56	1.21	2.59

Average Metropolitan	341	2.62	83.62
Average Metro-Rural	46	1.09	3.37
Average Non-Metro Rural	66	1.12	2.19

Average Disparity Ratio	7.75	2.61	28.97

Physicians / 1,000 Population

The “Doc/1,000 population” ratio demonstrates that the metropolitan areas have a disproportionately large number of physicians, and therefore each community member in the “city” has proportionately easier access to a physician, than does her/his rural counterpart. The metropolitan areas averaged 2.62 physicians per 1,000 population, while the metro-attached rural areas averaged 1.09. The rural areas with no metropolitan area averaged only slightly higher, with 1.12 physicians per 1,000 population. Any argument that because there are fewer persons in rural areas the access is really equal, is effectively negated.

This ratio also demonstrates another important point. The rural areas attached to metropolitan centers are more homogeneous in their physician density than the metropolitan areas themselves (metropolitan spread = 1.42 (high = 3.5, low = 2.08), rural spread = 0.75 (high = 1.48, low = 0.73)). We may be able to infer, therefore, that regardless of the way any particular metropolitan market develops, the surrounding rural market will develop with characteristics indigenous to “metro-attached rural markets,” and that those characteristics are fundamentally unrelated to the specific makeup of the health care offerings of the attached metropolitan area.

The two non-metropolitan-attached rural areas demonstrated even more homogeneity, in that the spread in their Doc/1,000 Population ratios (1.03 and 1.21) was only 0.18. Although it is known that some of these physicians are specialists, most are primary care physicians.

Physicians / 1,000 Square Miles

The measurement of “Docs per 1,000 miles²” shows a disparity of access in that the travel distance to a physician is vastly different in the rural areas, vs. the metropolitan areas. The average for metropolitan areas is an astounding 83.6 physicians per 1,000 miles², for metropolitan-attached rural areas 3.37, and for non-metro-attached rural areas, 2.19 physicians per 1,000 miles².

As above, the rural areas attached to metropolitan centers are more homogeneous in their physician density than the metropolitan areas (metropolitan spread = 149.73 (high = 178.75, low = 29.02), rural spread = 2.82 (high = 4.6, low = 1.78)). And again, the two non-metropolitan-attached rural areas demonstrated the most homogeneity, with a spread of 0.81 (values of 2.59 and 1.79.)

This truly is an issue of access. A one-thousand mile² area comprises a square of 31.6 miles on a side, for instance. Rural areas often have less than 2 physicians in that square, and any way you consider it, it can be a long trip to the doctor. And when a rural market has 5 or perhaps 6 doctors in a single clinic setting, the thousand-mile² area next door may not have any. The trip gets very much longer – up to 75 miles in some parts of Montana.

Specialization and Technology

Without a doubt, metropolitan areas offer centers where specialists and sub-specialists can ply their trade, and enjoy a plethora of technologically advanced instrumentation with which to work. And without a doubt, these centers are absolutely necessary to the good health of both city-dwellers, and rural-dwellers. Without performing a much more in-depth study than this, it is impossible to discern what the real impact on “primary” health care is.

Conclusion

This simple study demonstrates two things: Firstly, given that there is some kind of a relationship between the number of providers per 1,000 population in a rural area and its healthcare organization’s profitability, the low physician-density in metro-attached rural areas of Montana may be a contributing factor to the financial performance of those facilities, along with the pressure of specialist availability in the metropolitan areas. We plan to re-evaluate the financial performance data previously studied, to see whether this hypothesis is borne out. Secondly, without specifically discerning between primary care physicians and specialists, it is not possible to adequately address the issue of true access to primary physician health care expertise.

It is clear, however, that the demonstrated disparity of physician density tends to perpetuate itself, in that centers of population are able to recruit specialists, technology, and thus health care wealth, at the expense of their rural neighbors.

Resources

Number of Physicians by Montana County from the Montana Medical Association

Montana County Demographic Data (population and size) from Montana Department of Commerce http://commerce.mt.gov/censusresources.asp

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