By Dr. Patrick Jones
Access is a buzzword in healthcare reform circles, for good reason. Without an easy path for residents to receive clinical services, improvements to population health remain a dream.
Access takes on a few dimensions. One is the ability of residents to afford a visit to a provider. Thankfully, the introduction of the Affordable Care Act has fundamentally increased the provision of health insurance to thousands in the greater Tri Cities. As indicator 6.4.5 shows, Census (the American Community Survey) estimated that for 2022, about 90% of all residents had some form of health insurance. In 2011, about 81% did.
Another dimension of access is the ease of visiting a provider. Although a visit might mean an internet connection for telehealth, in most cases ease refers to transportation solutions. Without a car or bus services, appointments can’t be kept.
Insurance coverage and ease of visits provide a still incomplete assessment of access. We need to consider the number of workers wearing white coat and scrubs. Trends indicator 6.4.8 tracks a significant part of the provider community – licensed physicians.
As one can quickly see from the graph, the number of physicians surged between 2016 and 2017 to nearly 800; since 2018, however, the number has remained relatively flat. Tracked by number of physicians per 1,000 residents, the ratio peaked in 2020 and slumped a bit in 2021 to 2.8 per 1,000 residents. That was the same result in 2017. (The most recent data available stem from 2021.)
Further, the “density” of physicians here is much lower than throughout the state. For 2021, the WA rate was 4.2 per 1,000 residents, over 50% higher than in the two counties. Between the two counties, a substantial variation held in 2021: 3.6 per 1,000 in Benton County versus 1.1 in Franklin County. Clearly, the healthcare center of gravity is on the west side of the Columbia. While some travel is often expected to visit specialists, that may not (and should not) be the case for primary care.
Primary Care & Specialty Physicians
The data source for this indicator, the Washington Office of Financial Management (OFM), gives more detail to help us understand the physician profile in the metro area. Take primary care providers (PCs). This number in this category is typically defined as the sum of the following specialties: family practice, internal medicine, obstetrics/gynecology and psychiatry. In 2021, Benton County claimed 1.0 per 1,000 residents versus a mere 0.4 in Franklin County.
Statewide, the average was 0.9 PCPs per 1,000 residents. An approximate weighted average of the two local counties in 2021 was 0.8. So, the metro area is a bit PCP-lite.
That is not the case for specialists. The total from these various disciplines summed to 0.3 per 1,000 residents in Benton County in 2021. In Franklin County: 0.07. The state average for all specialists: 0.2. When the two counties are considered together, they showed 0.2 specialists per 1,000 residents in 2021. In light of the ability of the greater Tri Cities to offer more tertiary care, this relative abundance of specialists make sense.
Other Healthcare Providers
Physicians, of course, are not the only providers of healthcare. Nurses typically provide the bedrock of most clinics and hospitals. OFM does not provide data on nurses, registered (RN) or licensed (LPN). But another source, Washington’s Department of Employment Security (ESD), does, based on a survey.
Recent survey data of nurses reveal a somewhat different picture than for physicians. In 2023, the number of nurses per thousand residents in the metro area was 7.6. This represents a substantial bump from 2017, when the ratio stood at 5.7. Compared to the Washington average, however, nursing density in the greater Tri Cities still lags. In 2023, the ESD survey pointed to an average number of LPNs or RNs per 1,000 of 9.0.
Consider, too, Advanced Register Nurse Practitioners (ARNP). In the case of ARNPs, local density is actually higher here than statewide. According to OFM, the approximate average for the two counties in 2021 was 0.9 per 1,000 vs. 0.8 per 1,000 statewide. Clearly ARNPs are far fewer than nurses and physicians. But their numbers and rates have grown substantially since 2017 and the local provider community is “ahead of” the state.
Of course, there are other provider occupations that provide essential healthcare services. Space doesn’t permit a detailed dive into them all. But consider one of the high-demand professions – certified nursing assistants (CNAs). Like nurses and ARNPs, local numbers and rates per 1,000 residents have grown substantially between 2017 and 2023. In 2017, the CAN density was 2.4; by 2023, the ESD survey showed 3.0 per 1,000 residents. Nonetheless, the local rate still lags behind the Washington average of 3.6.
To recap, then, the local density of some key providers has recently experienced significant improvement. But that hasn’t been the case for physicians.
If the ultimate goal of indicator 6.4.5 is to track access to care, there’s a final consideration: the kind of insurance a patient carries. From many studies, we know that providers, in particular many physicians, limit the number of Medicaid patients in their panel. Without a survey, we don’t know how large that average share is in the two counties. We do know, however, that most of the gains in acquiring health insurance the greater Tri Cities has been due to Medicaid.