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On this page: Project Description | Study Methodology | State Summary | Workforce Supply and Demand | Health Professions Education | Physician Practice Location | Licensure and Regulation of Practice | Improving the Practice Environment | Exemplary Workforce Legislation, Programs and Studies | Policy Analysis | Data Sources

PROJECT DESCRIPTION

Historically, both federal and state governments have had a role in developing policy to shape the health care workforce.  The need for government involvement in this area persists as the private market typically fails to distribute the health workforce to medically underserved and uninsured areas, provide adequate information and analysis on the nature of the workforce, improve the racial and ethnic cultural diversity and cultural competence of the workforce, promote adequate dental health of children, and assess the quality of education and practice. 

It is widely agreed that the greatest opportunities for influencing the various environments affecting the health workforce lie within state governments. States are the key actors in shaping these environments, as they are responsible for:

• financing and governing health professions education;

• licensing and regulating health professions practice and private health insurance;

• purchasing services and paying providers under the Medicaid program; and

• designing a variety of subsidy and regulatory programs providing incentives for health professionals to choose certain specialties and practice locations.

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  This initiative to compile in-depth assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues, influences and policies. 

Products of this study include individual health workforce assessments for each of the eight states and a single assessment that compares various data and influences across the eight states.  In general, each state assessment provides the following:

1. A summary of health workforce data, available resources and a description of the extent the state invests in collecting workforce data.  [Part of this information has been provided by the Bureau of Health Professions];
2. A description of various issues and influences affecting the health workforce, including the state’s legislative and regulatory history and its current programs, financing and policies affecting health professions education, service placement and reimbursement, planning and monitoring, and licensure/regulation;
3. An assessment of the state’s internal capacity and existing strategies for addressing the above workforce issues and influences; and
4. An analysis of the policy implications of the state’s current workforce data, issues, capacity and strategies.

The development of the project’s data assimilation strategy, content and structure was guided by an expert advisory panel.  Members of the advisory panel included both experts in state workforce policy (i.e., workforce planners, researchers and educators) and, more broadly, influential state health policymakers (i.e., state legislative staff, health department officials).  The advisory panel has helped to ensure the workforce assessments have an appropriate content and effective format for dissemination and use by both state policymakers and workforce experts/officials.

STUDY METHODOLOGY

1. States with limited as well as substantial involvement in one or more of the following areas: statewide health workforce planning, monitoring, policymaking and research;
2. States with presence of unique or especially challenging health workforce concerns or issues requiring policy attention;
3. States with little involvement in assessing health workforce capacity despite the presence of unique or especially challenging health workforce concerns or issues requiring policy attention;
4. Distribution of states across Department of Health and Human Services regions;
5. States with Bureau of Health Professions (BHPr) - supported centers for health workforce research and distribution studies;
6. States with primarily urban and primarily rural health workforce requirements; and
7. States in attendance at BHPr workforce planning workshops or states that generally have interest in workforce modeling.

Collection of Data

NCSL used various means of collecting information for this study.  Methods exercised included:

1. Phone and mail interviews with state higher education, professions regulation, and recruitment/retention program officials;
2. Custom data tabulations by national professional trade associations and others (i.e., Quality Resource Systems, Inc.; Johns Hopkins University School of Public Health) with access to national data bases;
3. Tabulations of data from the most recent edition of federal and state government databases (e.g., National Health Service Corps field strength);
4. Site visit interviews with various officials in the eight profile states;
5. Personal phone conversations with other various state and federal government officials;
6. Most recently available secondary data sources from printed and online reports, journal articles, etc.; and
7. Comments and guidance from members of the study’s expert advisory panel.

STATE SUMMARY

Georgia, though largely rural, is a rapidly growing state that is becoming more urbanized.  The proportion of the population that is minority or ethnic—largely African-American—exceeds the national figure.  Although the proportion of the state’s population that lacks health insurance mirrors the national average, Georgia’s rural and inner-city population lacks adequate geographical access to basic health care services.  The percent of the population residing in primary care and dental federally-designated health professional shortage areas (HPSAs) exceeds the national proportion. 

According to recent reports, rural and poor urban areas of the state continue to have difficulty recruiting primary care physicians, despite the fact that the state and federal governments have several programs to spur provider recruitment and retention in these communities.  The state’s community health centers in underserved areas voice growing concerns about their difficulty recruiting and retaining physicians and dentists.  State officials rank state programs that now support health professions education in underserved areas (i.e., Georgia’s Area Health Education Centers) as having a highly favorable impact on provider recruitment and retention. 

Anecdotal information also suggests that low Medicaid reimbursement rates are having an increased impact on Medicaid participation by physicians and dentists, particularly in largely underserved areas of the state. The state’s current fiscal crisis continues to plague support for Medicaid and other state health care programs.  Budget cuts in recent years have forced reductions in Medicaid reimbursement rates to most providers.  Across-the-board cuts to most other state programs has also forced reductions in many health professions training programs and provider recruitment and retention initiatives.  

The state appears to suffer an overall shortage as well as maldistribution of physicians, nurses and dentists. In response to the state’s shortage of nurses and many other non-physician health professionals, the legislature in 2001 created a standing policy committee to address these shortages.  (Georgia’s Board for Physicians Workforce has been charged with addressing physician supply issues, and has produced several reports documenting the problem and offering solutions.)  The Health Care Workforce Policy Advisory Committee convened with the charge of monitoring and addressing ongoing workforce supply and demand issues in four areas:  education programming and financing; data and forecasting; work environment and enhanced productivity; and recruitment and marketing.  The Committee realized several accomplishments in the first year and beyond of its existence by helping to establish several new initiatives in the state. 

Despite the creation of these and other new initiatives, shortages of nurses and allied health personnel, particularly in hospitals, have not dissipated.  The state hospital association voices concern with a growing vacancy rates for nurses (13% in 2002), pharmacists (particularly in rural hospitals) and other health personnel.  Although the state's changing demand for and supply of nurses is becoming better understood, there is a consensus that the nursing shortage in Georgia, like elsewhere, is largely associated with an insufficient capacity of nurse training programs associated with shortages of faculty, space and other resources to educate more nurses.  Increasing numbers of qualified applicants are being turned away from nursing schools.  Georgia’s nursing shortage is one of the worst nationwide.  In response to recent sample surveys of licensed nurses in the state, almost 45 percent of the RNs respondents expect to work for less than another ten years.

Georgia’s physician supply is not keeping pace with the state’s rapidly growing population.  A shortage of specialty physicians statewide is becoming evident.  Despite that fact the state has four medical schools, Georgia is heavily dependent on other states to train its demand for physicians.  About 70 percent of the state’s practicing physicians completed their training in another state, and the number of applicants to the state’s medical schools has declined over the past five years.  Growing concern with rising physician malpractice insurance premiums have raised new fears of many physicians curtailing or closing their practices. 

Although there is growing concern that Georgia faces an overall shortage of dentists in the near future, oral health experts agree that the state’s dental workforce shortage now is largely a maldistribution problem.   However, according to recent sample surveys of practicing dentists in the state, more than 45 percent indicate they plan to retire within 10 years.  Dentist maldistribution in rural areas is becoming particularly acute.   Georgia still requires applicants for licensure in the state to complete their own exams.  The licensing board does not recognize regional exams or license by credentialing.  Such requirements are often viewed as constraining the state’s supply of dentists.

I.  WORKFORCE SUPPLY AND DEMAND

Arguably, it is most important initially to understand the marketplace for a state’s health care workforce.  How many health professionals are in practice statewide and in medically underserved communities?  What are the demographics of the population served?  How is health care organized and paid for in the state?  This section attempts to answer some of these questions by presenting state-level data collected from various sources.

Table I-a.

Sources:  U.S. Census Bureau, AARP.

Nearly 40 percent of Georgia’s residents are identified as minority or ethnic.

Table I-b.

Sources: CDC, AARP, GAO.

More Georgia adults reported having routine physical exams within the past two years than the national average. Table I-c.

HPSA = Health Professional Shortage Area

Sources: KFF, AARP, BPHC-DSD.

Georgia has a higher percentage of population living in primary care HPSAs than the U.S. as a whole. The state also has a higher percentage of population not obtaining health care due to cost.

Table I-d.

RN= Registered Nurse, LPN= Licensed Practical Nurse, CNM= Certified Nurse Midwife, NP= Nurse Practitioner

CRNA= Certified Registered Nurse Anesthetist

Source: HRSA-BHPr.

Georgia has a significantly higher proportion of physicians who are International Medical Graduates than the U.S. as a whole.

Table I-e.

HPSA= Health Professional Shortage Area

Source: BPHC-NHSC.

Georgia has less NHSC professionals per 10,000 population living in HPSAs than the U.S. as a whole. Table I-f.

MCOs = Managed Care Organizations    HMOs = Health Maintenance Organizations    OB/GYN = Obstetrician/Gynecologist

* This requirement does not preclude MCOs from including additional professions on their provider panels.

Sources: HPTS, AARP.

Only fifteen percent of Georgia residents receive their health care from an HMO.

Table I-g.

¹ Generally seen as an indicator of significant participation in the Medicaid program.

² Denominator number from HRSA State Health Workforce Profile, December 2000.

Table II-a.

¹ Denominator number is state population from 2000 U.S. Census.

Sources: AAMC, AAMC Institutional Goals Ranking Report, AACOM, Barzansky et al. “Educational Programs”, State higher education coordinating boards.

Nearly eighty percent of newly entering medical school students are state residents.  Only seven percent of medical school graduates in Georgia are underrepresented minorities. Table II-b.

¹ Includes estimated number of osteopathic residencies/residents not accredited by the Accreditation Council for Graduate Medical Education.
² Does not include residents from Canada.
³ Explicit payments for both direct and indirect GME cost.

Sources: AMA, AMA State-level Data, AACOM, State higher education coordinating boards, Henderson “Funding”, Oliver et al. “State Variations.”

Neither the state of Georgia nor most primary care residencies require training programs to offer some or all physician residents a rural rotation. Table II-c.

¹ Denominator number is state population from 2000 U.S. Census.

Sources: AAFP, AAFP State Legislation, Kahn et al., Pugno et al. and Schmittling et al. “Entry of U.S. Medical School Graduates”.

Only fourteen percent of medical school graduates in Georgia were first year residents in family medicine. Table II-d.

¹ Annual figure for Associate, Baccalaureate, Masters and Doctoral students/graduates for most recent years available.
² Denominator number is the state population from the 2000 U.S. Census.

Sources: NLN, AACN, State higher education coordinating boards.

The number of baccalaureate students in Georgia rose dramatically from 2001 to 2002. Table II-e.

* Denominator number is state population from 2000 U.S. Census.

Source: AACP.

Table II-f.

¹ Denominator number is state population from 2000 U.S. Census.

Sources: APAP, APAP Annual Report.

Table II-g.

* Denominator number is state population from 2000 U.S. Census.

Source: ADA.

Table II-h.

* Denominator number is state population from 2000 U.S. Census.

Sources: ADHA, AMA Health Professions.

¹ 1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale. Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to metro area

NA: Not Applicable; no counties in the state are in the R/U Continuum Code.

Practice location (URBAN/ RURAL) of physicians who received their most recent GME training in Georgia between 1978 and 1998.

Table III-b.

¹  1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale.  Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to metro area

NA: Not Applicable; no counties in the state are in the R/U Continuum Code.

IV.  LICENSURE AND REGULATION OF PRACTICE

States are responsible for regulating the practice of health professions by licensing each provider, determining the scope of practice of each provider type and developing practice guidelines for each profession.  The tables below illustrate the licensure requirements for each of the health professions covered in this study as well as additional information on recent expansions in scope of practice or other novel regulatory measures taken by the state.

Table IV-a.

Sources: State licensing board, HPTS.

Table IV-b.

Source: State licensing board. Table IV-c.

Sources: State licensing board, AANA, ACNM, Pearson “Annual Legislative Update”, HPTS. Table IV-d.

Source: State licensing board.

Table IV-e.

Source: State licensing board.

Table IV-f.

Source: State licensing board, ADHA.

Glossary of Acronyms

CNM: Certified nurse midwife.

CRNA: Certified registered nurse anesthetist.

DEA:  Drug Enforcement Agency.

HPSA: Health Professional Shortage Area

NCLEX: National Council Licensure Examination, administered by the National Council of State Boards of Nursing.

NP: Nurse practitioner.

RDHAP: Registered dental hygienist in alternative practice.

V.  IMPROVING THE PRACTICE ENVIRONMENT

States have the challenge of not only helping to create an adequate supply of health professionals in the state, but also ensuring that those health professionals are distributed evenly throughout the state.  Various programs and incentives are used by states to encourage providers to practice in rural and other underserved areas.  The tables in this section describe Georgia’s programs as well as the perceived effectiveness of these programs.

RECRUITMENT/ RETENTION INITIATIVES

Table V-a.

Source: State health officials.

N/A = Data was not available. 

Georgia has established various recruitment and placement programs for most of the major health professions.

LOAN REPAYMENT/ SCHOLARSHIP PROGRAMS *

Table V-b.

* Includes only state-funded programs which require a service obligation in an underserved area. (NHSC state loan repayment programs are included since the state provides funding.)

Source: State health officials.

WORKFORCE PLANNING ACTIVITIES*

Table V-c.

* One state health official supplied these responses. Therefore, data may be limited and may not accurately reflect all current workforce-planning activities in the state.

Georgia collects data  and produces reports on most of the major health professions and encourages data collection for all of the major health professions.

VI.  EXEMPLARY WORKFORCE LEGISLATION, PROGRAMS AND STUDIES

The following abstracts describe several of Georgia’s recent endeavors to understand and describe the status of the state’s current health care workforce.

Legislation and Programs

H-156 (2001)

This law requires the Board of Medical Examiners to create physician profiles for license physicians.  The profile must include the physician’s educational background, board certification, practice history, hospital privileges, and any disciplinary actions taken against the physician.

Certified Nurse Anesthetist (CNAs)-Licensed Practical Nurse (LPNs)- Scholarship

• Georgia Department of Community Health
• Health Care Workforce Policy Advisory Committee
• Health Care Workforce Data Consortium
• Statewide Area Health Education Centers Network
• Georgia Board for Physician Workforce

Evidence of Collaboration:  Significant (largely associated with workforce data collection/analysis and profession recruitment and retention)

Georgia, though largely rural, is a rapidly growing state that is becoming more urbanized.  The proportion of the population that is minority or ethnic—largely African-American—exceeds the national figure.  Although the proportion of the state’s population that lacks health insurance mirrors the national average, Georgia’s rural and inner-city population lacks adequate geographical access to basic health care services.  The percent of the population residing in primary care and dental federally-designated health professional shortage areas (HPSAs) exceeds the national proportion. 

According to recent reports, rural and poor urban areas of the state continue to have difficulty recruiting primary care physicians, despite the fact that the state and federal governments have several programs to spur provider recruitment and retention in these communities.  The field strength of National Health Service Corps personnel per 10,000 population residing in Georgia HPSAs was just below the national ratio in 2003.  The state’s community health centers in underserved areas voice growing concerns about their difficulty recruiting and retaining physicians and dentists.  State officials rank state programs that now support health professions education in underserved areas (i.e., Georgia’s Area Health Education Centers) as having a highly favorable impact on provider recruitment and retention.  Moreover, Medicaid payment bonuses or other incentives for dental practice in such locations also receive high marks.  The state’s physician scholarship and loan repayment programs also report that average retention rates in underserved areas for their recipients exceed fifty percent.

Anecdotal information also suggests that low Medicaid reimbursement rates are having an increased impact on Medicaid participation by physicians and dentists, particularly in largely underserved areas of the state.  In 2003, for example, just 39 percent of all practicing dentists were enrolled in Medicaid, and of those, just 39 percent reported receiving annual Medicaid payments from services greater than $10,000.

The state’s current fiscal crisis continues to plague support for Medicaid and other state health care programs.  Budget cuts in recent years have forced reductions in Medicaid reimbursement rates to most providers.  Across-the-board cuts to most other state programs has also forced reductions in many health professions training programs and provider recruitment and retention initiatives.  In early 2004, there was talk of using the state’s tobacco fund reserves to cease several health care cuts, including elimination of Medicaid adult dental coverage, proposed by the governor to address budget shortfalls.

The state appears to suffer an overall shortage as well as maldistribution of physicians, nurses and dentists.  In response to the state’s shortage of nurses and many other non-physician health professionals, the Department of Community Health established in 2000 technical advisory committee which issued a report, “Code Blue: Workforce in Crisis”, to policymakers documenting the shortages and recommending various action strategies.  Effective in 2001, the legislature created a standing policy committee to address the shortages documented in the report.  (Georgia’s Board for Physicians Workforce has been charged with addressing physician supply issues, and has produced several reports documenting the problem and offering solutions.)  The Health Care Workforce Policy Advisory Committee convened with the charge of monitoring and addressing ongoing workforce supply and demand issues in four areas:  education programming and financing; data and forecasting; work environment and enhanced productivity; and recruitment and marketing.  A follow-up report on the progress of the Committee was issued in 2003.

The Committee realized several accomplishments in the first year and beyond of its existence.  Some of these include:

• Expansion in state support for profession education and training programs in nursing and allied health, many involving the establishment of public-private partnerships;
• Expansion of Georgia’s Service Cancelable Loan program to support students in health careers;
• Creation of a Nursing Faculty Loan Program (through the Georgia Student Finance Authority) jointly supported by labor and a private foundation, and using the state’s workforce investment boards to support bridge scholarships that allow entry-level health workers to gain skills and move into licensed nursing positions;
• New legislation providing for new data collection from licensees and funding for a Health Care Workforce Integrated Data System;
• Convened regional forums with health care management and labor groups to identify best practices reflecting workplace excellence, and issued a report of such discussions;
• Developed various recruitment and marketing programs to promote health careers in the state.

The Committee’s continued work calls for establishing regional recruitment and workforce resource clearinghouses in conjunction with AHECs, implementing various recruitment and education initiatives in partnership with other state agencies, promoting success and continued expansion of innovative higher education programs, and structuring regulatory and financing incentives to promote workplace excellence.  In the past year, due to the state’s budget problems, funding for the work of the Committee and other statewide health workforce initiatives is being reduced and threatens the scope of future state government work on this issue.

To further address  health workforce shortages in the state, Georgia in 2002 expanded its successful University System’s Intellectual Capital Partnership Program (ICAPP).  Modeling after the Program’s  economic development incentive initiative, the expansion creates a health professionals initiative.  The public-private partnership includes a state investment for health professions training program-related expenses at 13 institutions in the state’s university system matched by cash and in-kind contributions by Georgia’s health care providers wishing to employ graduates of these training programs to meet their workforce needs.  Initial plans for the initiative called for participating institutions to educate more than 500 new health professionals over two years.

Despite the creation of these various new programs, shortages of nurses and allied health personnel, particularly in hospitals, have not dissipated.  The state hospital association voices concern with a growing vacancy rates for nurses (13% in 2002), pharmacists (particularly in rural hospitals) and other health personnel.  Current budget shortfalls have caused funds for the new service cancelable loan program to be depleted.  There are growing calls as well to increase support for other state health professional scholarship and loan programs.  

Another growing concern are rising physician malpractice insurance premiums.  Recent studies by the Georgia Board for Physician Workforce suggest that these rate increases are forcing many physicians in the state to curtail or close their practices.  However, a medical tort reform measure passed by the legislature in 2003 appears to have limited impact on controlling premium increases and provides no cap on damages awarded from malpractice litigation.

In general, Georgia’s physician supply is not keeping pace with the state’s rapidly growing population.  A shortage of specialty physicians statewide is becoming evident.  Despite that fact the state has four medical schools, Georgia is heavily dependent on other states to train its demand for physicians.  About 70 percent of the state’s practicing physicians completed their training in another state, and the number of applicants to the state’s medical schools has declined over the past five years.

Nursing

Although the state's changing demand for and supply of nurses is becoming better understood, there is a consensus that the nursing shortage in Georgia, like elsewhere, is largely associated with an insufficient capacity of nurse training programs (associated with shortages of faculty, space and other resources) to educate more nurses.  Increasing numbers of qualified applicants are being turned away from nursing schools.  Georgia’s nursing shortage is one of the worst nationwide.  In response to recent sample surveys of licensed nurses in the state, almost 45 percent of the RNs respondents expect to work for less than another ten years.  The efforts of the state’s Health Care Workforce Policy Advisory Committee to better understand and address these issues, although not sufficient to fully address the problem, receives widespread support in the nursing community.

Dentistry

Although there is growing concern that Georgia faces an overall shortage of dentists in the near future, oral health experts agree that the state’s dental workforce shortage currently is largely a maldistribution problem.  However, according to recent sample surveys of practicing dentists, more than 45 percent indicate they plan to retire within 10 years.  Dentist maldistribution in rural areas is becoming particularly acute.  The state’s one dental school attempts to address this inequity in its admission policies.  The school now partners with the state’s AHECs to find disadvantaged youth and make them competitive applicants and to introduce students to community-based training in rural and underserved communities. 

Georgia still requires applicants for licensure in the state to complete their own exams and does not recognize regional exams or license by credentialing.  Such requirements are often viewed as constraining the state’s supply of dentists.

Although the overall supply of dental hygienists in Georgia appears to be adequate, the demand for hygienists in rural areas of the state, however, looks to be exceeding their supply.  The total count of hygienists statewide exceeds that of dentists, and the state has 13 hygiene training programs.

Data Sources