Targeting Rural Health Care Workforce Investments by Tracking the Local Distribution of Medicaid Primary Care Providers

The newly launched Rural Health Transformation Program (RHTP) invests $50 billion dollars towards strengthening health care across rural America, including by creating sustainable access to rural health care providers and improving workforce development. As states prepare proposals for the RHTP, they need a clear understanding of the workforce available to serve these populations, especially the primary care workforce available to rural Medicaid beneficiaries. The U.S. Medicaid Primary Care Workforce Tracker is the only source of national-level claims of Medicaid beneficiaries’ health care utilization and the workforce that delivered care to them — and it now provides an option to view providers by rural area at the county level.  

By grounding RHTP and other investment decisions in these data on the geographic and professional distribution of the primary health workforce, states can help ensure limited funds yield the greatest possible impact on health outcomes, access to care, and workforce sustainability.

Tracking the Primary Care Workforce in Medicaid

Developed by the Mullan Institute for Health Workforce Equity at the George Washington University, the Tracker leverages the multi-state claims data from the Transformed Medicaid Statistical Information System Technical Analytic Files between 2016-2021. It collects Medicaid and Children’s Health Insurance Program data from US states, territories, and Washington, DC, including fee-for-service and managed care plan data. To determine a county’s rurality designation, the tracker uses data from the Federal Office of Rural Health Policy.

The Tracker offers an interactive map that allows the users to visualize the primary care workforce providing health care to individuals with Medicaid. It provides states with the ability to benchmark their Medicaid primary care workforce against other states, assess participation across professions and specialties, map county-level distribution, and track trends in workforce supply over time.

Illustrative Findings

National

Data from the Tracker is consistent with other research documenting substantial rural workforce challenges. To assess local health workforce, we used Medicaid participation among primary care clinicians as a proxy for supply. Pairing this with county-level Medicaid enrollment, we calculated provider-to-population ratios, which account for differences in population density. Our analysis revealed a persistent disparity: from 2016 to 2021, across every specialty, rural counties had significantly fewer Medicaid-participating primary care providers per 100,000 enrollees than their urban counterparts (Figure 1). Further, these ratios remained fairly stable by specialty and profession, with the exception of nurse practitioners (NPs), whose numbers have increased from 165 per 100,00 population in 2016 to 236 in 2021 in rural areas (Figure 2). We also found that a significantly higher percentage of rural counties are primarily served by NPs and physician associates (PAs).

Figure 1: Counties in the Bottom Quartile of the Provider to Population Ratio by Rurality

* Authors’ analysis using data from the Medicaid tracker
** Analysis includes counties from 40 states with good data quality in all years
** Bottom quartile in terms of provider-to-population ratio: minimum 21 providers to maximum 296 providers

Figure 2: Provider-to-Population Ratio by Primary Care Specialty and Rurality

* Authors’ analysis using data from the Medicaid tracker
** Analysis includes counties from 40 states with good data quality in all years

Figure 3: Counties Primarily Served by NPs and PAs

* Authors’ analysis using data from the Medicaid tracker
** Analysis restricted to providers with ≥ 5 Medicaid beneficiaries, practicing in counties from 40 states with good data quality in all years
*** Primarily = more than 50% county providers were nurse practitioners (NPs) or Physician Associates (PAs)

State and County

While national-level data is valuable, the tracker is particularly helpful in elucidating comparisons and trends at the state and county levels, revealing important variations within states, even among rural counties only. Given that not all rural counties have the same challenges, the Tracker can be used to examine workforce gaps within a state to identify solutions specific to a particular community’s workforce needs. Below, we provide examples to illustrate the kinds of variation and problems that states may wish to address.

In many states, there are counties with no providers. For example, we see that in Georgia, there are eight counties with no providers who served at least 11 Medicaid patients in the year 2021 (Figure 4). For these types of counties, states may want to focus investment on telehealth infrastructure or the opening of new community health centers. States may also want to incentivize recruitment to those counties through programs like the Conrad 30 program and loan repayment programs.

Figure 4: Primary Care Providers Seeing 11 or More Medicaid Beneficiaries in Georgia, 2021, by County

*Shown in white 

Low Medicaid participation rates are also an issue in some counties, such as in Florida, where most counties are in the bottom quartile for the percentage of providers who accept Medicaid. These states may want to focus efforts on providers who are not currently participating in Medicaid. Continuing the example of Georgia’s counties with no providers, if the providers who only saw between 1-10 Medicaid patients in 2021, and the providers who are likely active but not seeing Medicaid patients, were convinced that they should accept Medicaid, half of the eight no-provider counties would no longer be without providers. Policies to enhance participation might include reducing administrative burden, increasing payment rates, or adding bonus payments for providers that are in specific high-risk counties.

Some counties lack specific specialties, such as OBGYNs. In West Virginia, for example, there are large clusters of counties with no maternal care providers. By searching for counties with OBGYNs or midwives, we can see 14 adjacent counties in West Virginia that have no OBGYNs or midwives, suggesting an urgent need to investigate, first, whether there are women’s health care vacancies in those counties, and then to target investments to either creating jobs and/or incentivizing professionals to move to those areas (Figure 5).

Figure 5: Counties in West Virginia With no OBGYNs, 2021*

*Shown in white

Many counties rely exclusively on NPs and PAs. In Georgia, for example, 13 out of 120 rural counties have only NPs and no other provider type. Sixteen more counties have only NPs and PAs. In this context, states may wish to implement policies to support this advance practice workforce, including enhancing the infrastructure for team-based care, expanding scope of practice policies at the state and organizational level, developing NP residency programs, and/or increasing Medicaid reimbursement policies for NPs.

Lastly, longitudinal analyses can highlight counties and provider types that are falling or increasing faster than the state or national average. In Idaho, for example, while the primary care provider-to-population ratio is higher than the national average, there was a downward turn from 2019 to 2021, even as the national trend continued to rise (Figure 6). Drilling down, the Tracker allows us to identify which counties and professions are driving the decline. States will need to investigate causes of such declines, but one explanation may be rural hospital closures, making it even more important to enhance the primary care infrastructure, such as community health centers and school-based clinics, in addition to developing the other strategies mentioned earlier.

Figure 6: Idaho Medicaid Primary Care Provider-to-Population Ratio Idaho and National Average, 2016-2021

Proving New Insights

The Tracker is designed to provide new insights into provider participation, specialty mix, and geographic distribution. It is not intended to be prescriptive; the goal is to give users information to identify workforce strategies that best meet their individual priorities and resources. We will continue updating the Tracker as new data becomes available, enabling users to monitor workforce changes over time, especially in response to RHTP funding and other investments.