Arizona Primary Care Residency Training Assessment and

Development Project

Funded by the Arizona Area Health Education Centers (AHEC) Program at the

University of Arizona, Tucson, AZ

Doug Campos-Outcalt, M.D., M.P.A.

Joe Tabor, Ph.D., M.P.H.

Phil Lopes, M.A.

Ed Paul, M.D.

Communication regarding the report should be sent to dougco@email.arizona.edu

2

Introduction

Arizona has a physician shortage. The state ranks 35th in the country with 218.3 physicians per 100,000

population compared to the national average of 255.8/100,000.1 (See Figure 1) In Arizona there are 14,398

active allopathic physicians and 1,615 active osteopathic physicians. To arrive at the national average we would

need an additional 2,475 physicians (a 15% increase over the current number).

Figure 1

Active Physicians per 100,000 Population by Degree Type, 2009 1

3

The physician shortage is more pronounced for primary care physicians than for specialists in Arizona and the

U.S. Only 38.2% of active physicians in Arizona are in primary care practices, defined as family medicine, general

practice, general internal medicine, general pediatrics, and obstetrics and gynecology2. As of June 30, 2011 in

the U.S. there were 6,422 primary care Health Professional Shortage Areas (HPSA’s) representing 66.6 million

people in both urban and rural areas. This equates to an estimated national shortage of 17,696 primary care

providers.3

The physician shortage is also more marked in rural areas than urban. Figure 2 shows the physicians per

population rate for all physicians for four rural-urban commuting areas (RUCA) of residence--urban, large rural

towns, small rural towns, and isolated small rural towns-- for the years 2002 through 2006. RUCAs are a

standard, nationwide classification of rural at postal zip code resolution. They are based on their proximity to

urban areas and the portion of the population that commute between rural and urban areas and are

approximately the same as US Office of Management and Budget’s metro classification. 4,5 Table 1 lists the

primary care physicians per population rate and Table 2 the specialists per population rate in the four RUCA

categories. These two tables illustrate that primary care physicians distribute themselves more evenly

throughout the state than do specialists. This is likely due in part to the population base needed to support

highly specialized practices.

Figure 2 2

Total Physicians (MD and DO) per 100,000 Population Profile for Arizona’s Four Rural Urban Commuting Areas:

2002-2006

Sources: Arizona Board of Medical Examiners Allopathic Physician Files 2008 and Arizona Department of Health Services, Arizona Primary Care Area Pro-

gram, Primary Care Area Osteopathic Physician Statistical Files, 2002-2006. Population estimates provided by Claritas.

4

Table 12

Primary Care Physicians (MDs and Dos) per 100,000 Population: Arizona’s Four Rural Urban Commuting Areas

(RUCA) Changes between 2002 and 2006

Table 2 2

Specialist Physicians (MDs and Dos) per 100,000 Population: Arizona’s Four Rural Urban Commuting Areas

(RUCA) Changes between 2002-2006

This report describes the current status of medical student and residency training in Arizona. It examines Arizona

physician workforce data to understand current supply and shortages by geography and specialty and explores

the current composition of the Arizona physician workforce to determine what contribution physicians trained

in the state, either in medical school and/or residency, are making to the workforce numbers in urban and rural

areas and in each county. The project also explores the characteristics of hospitals and hospital systems that do

and do not sponsor residency programs and reports on a survey of hospital directors about their interests, or

lack of, in sponsoring residency programs and the reasons behind these attitudes. Finally there are suggestions

about how the state’s training capacity might be expanded.

5

Medical Student Training in Arizona

Training to become a physician involves completing medical school, either allopathic (MD) or osteopathic (DO),

followed by residency training. Medical school lasts four years and residency training duration varies by

specialty, with three years of training required for most primary care specialties and three or more years for

specialty training. Some physicians complete multiple residencies, which further increases the lag time from

beginning medical school to becoming a practicing physician. It is possible to practice as a “general practitioner”

in Arizona after only one year of residency, which by definition means the physician has no specialty board

certification. However, very few new medical school graduates choose to be a general practitioner.

There are currently four medical school campuses in Arizona. Two are allopathic campuses of the University of

Arizona College of Medicine; one in Tucson and one in Phoenix. The Tucson campus was established in 1969 and

the Phoenix campus was established in 2006. There are two colleges of osteopathic medicine in the state. One is

the Midwestern University/Arizona College of Osteopathic Medicine (MWU/AZCOM), located in Glendale, the

other is the A. T. Still University School of Osteopathic Medicine in Arizona (ATSU-SOMA), located in Mesa. The

MWU/AZCOM was established in 1996 and ATSU-SOMA in 2007. In addition, the Kirksville College of

Osteopathic Medicine (KCOM), located in Missouri, sends approximately 30 students per year to Arizona for

their third and fourth year of training.

Table3 shows the growth of the Arizona population from 1990 to 2010 and the percentage of the U.S.

population living in Arizona. During this time period the Arizona population grew from 3.7 million people and 1.5

per cent of the U.S. population to 6.6 million people and 2.1 per cent of the U.S. population.

Table 3

Arizona Population Growth 1990-2010

1990 2000 2010

Arizona Population 3,665,000 5,130,000 6,596,000

U.S. population 248,710,000 248,100,000 307,000,000

Arizona % of the U.S. 1.5 1.8 2.1

Data obtained from the U.S. census bureau at http://quickfacts.census.gov/qfd/states/04000.html

Table 4 describes the trends in allopathic medical student education in Arizona and Table 5 the trends in

osteopathic medical student education. While the number of allopathic students trained in the state has

increased from 360 to 575 and the proportion of all medical students in the country who are trained in Arizona

also increased from 0.55 % to 0.8 %, the rate of medical students trained per 100,000 population has actually

declined from 9.8 to 8.7 and we remain well below the national rate of 24/100,000. These statistics will become

more favorable as the Phoenix campus grows and expands its class size. Within the next 10 years, the total

number of allopathic students being trained in the state should be 920, with 230 graduating each year.

6

The number of osteopathic students has grown at a much faster rate than allopathic. In 2010 20.8 per cent of all

medical students in the country were osteopathic, compared to 10 per cent in 1990. In Arizona the rate of

osteopathic students per 100,000 population (18.2) is well above the national rate of 6.3 and over 6 per cent of

all osteopathic students in the country are trained in Arizona. In Arizona 68.3 per cent of all medical students are

osteopathic compared to 20.8 per cent nationally. These numbers are also changing as the MWU/AZCOM is

expanding to 250 students per class, and if ATSU-SOMA remains at 100 per class there will be 1400 osteopathic

students trained in the state with 350 graduating each year.

In Arizona, if both allopathic and osteopathic training are taken into account, medical education has expanded

markedly and our current rate of medical students per 100,000 population (26.9) in 2010 is very close to the

national rate (30.3) and will exceed the national rate as growth in medical student education continues.

Table 4

Arizona Allopathic Medical Education 6-8

1990 2000 2010

Total Number of Medical Students USA

65,150 66,500 73,800

Number of Medical Students in Arizona

360 407 575

Az % of the total 0.55 % 0.6 % 0.8 %

Az Medical Students /100,000 population

9.8 7.9 8.7

US Medical Students /100,000

26.2 23.6 24.0

Table 5

Arizona Osteopathic Medical Education

1990 2000 2010 Total Number of Medical students USA

7,200 11,000 19,427

Number of Medical Students in Arizona

60 400 1200

Az % of the total 0.8 % 3.6 % 6.17 % Az Medical Students /100,000

0.16 7.8 18.2

US Medical Students /100,000

2.9 3.9 6.3

% of Arizona Medical Students who are Osteopathic

14% 50 % 68.3 %

% of all U.S Medical Students who are Osteopathic

10 % 14.4 % 20.8 %

7

Graduate Medical Education Training in Arizona

In contrast to the growth in medical student educational opportunities, the growth in post medical school

training in medical residencies (Graduate Medical Education or GME) has been more modest. Table 6 illustrates

this growth in GME training in Arizona from 1990 to 2010. These data were obtained from JAMA Medical

Education Issues. 9-11 The number of allopathic residency programs has increased between 1990 to 2010 from 67

to 114 and the number of trainees from 842 to 1,395. The proportion of residents in the country trained in

Arizona increased from 1.05 % to 1.27 %. However, the rate of residency positions per 100,000 population has

actually decreased, from 22.97 to 21.15 and remains far below the U.S. rate of 35.76. To equal the U.S rate

Arizona would need an additional 964 resident positions, or about 250 new first year positions.

Residency growth nationally is lagging behind growth in medical student education. This situation is especially

acute in Arizona because of its rapid growth in medical student training capacity and modest increase in the

number of allopathic residency programs and number of residency positions. Osteopathic training has not

contributed in any significant way to increasing residency capacity, although there have been several

osteopathic residencies started in rural parts of the state. The current 6 osteopathic residency training programs

in Arizona, with capacity for 76 residents, account for 3 per cent of the state’s total capacity for residency

training.

Table 6

Allopathic Residency Training in Arizona 9-11

1990-2010

1990 2000 2010

Number of Residency Programs in AZ

67 79 114

Number of AZ residents 842 1,039 1,395

Number of US residents.

80,200 98,000 109,800

National % in Arizona 1.05 % 1.06 % 1.27 %

Az residents /100,000 22.97 20.24 21.15

US residents /100,000 32.25 34.83 35.76

Difference 9.28 14.59 14.61

Appendices that relate to and further define the status of allopathic and osteopathic residency education in

Arizona appear at the end of this report. Appendix 1 lists, by specialty, the number of allopathic residency

training programs located in Arizona, the total number of programs in the U.S. and the number of resident

training positions available in the state. Appendix 2 lists, by specialty, the number of osteopathic training

programs in Arizona and their training capacities. Appendix 3 lists the specialties that have no training programs

8

in the state and the number of programs in those specialties in the U.S. Information on allopathic residency

programs for Arizona and the U.S. was obtained from the latest Graduate Medical Education Directory published

by the AMA.12 Information on Osteopathic residency programs was obtained from the AOA web site.13 For this

analysis and the Arizona physician workforce analysis that follows, primary care is defined as internal medicine,

pediatrics, family medicine and general practice; obstetrics and gynecology is not classified as primary care.

Currently about 39% of the allopathic residency training capacity in the state is for training of primary care

physicians (621 out of a total of 1593 positions) while 70% of the osteopathic residency capacity is for primary

care (53 out of 76 positions). The Arizona primary care residency programs are graduating around 230 physicians

each year. The number who will actually go on to practice primary care is smaller, however, because

traditionally half or more of pediatricians and internists continue in training to subspecialize.

Historically approximately one-fourth or more of all residency positions in the country have been filled by

international medical graduates (IMGs), including U.S citizens that study abroad. It is likely that the combination

of a growth in medical student training in the U.S. and the slow growth in the number of residency positions will

result in a smaller proportion of IMGs accepted into U.S. residency programs. Unless residency training capacity

increases the overall increase in the U.S. physician workforce will therefore be very slight, in spite of increases

that have occurred in the number of medical students trained.

In Arizona the current trends may result in more Arizona medical students remaining in the state for residency

training, although this is uncertain because many variables factor into the decisions residency program faculty

and medical students make regarding residency training location. The total number of physicians being trained

in Arizona residencies, those most likely to remain in the state to practice, may increase marginally through

increases in the size of existing residency programs but it will not keep up with population growth unless

residency capacity is expanded by the creation of new programs.

Arizona Physician Workforce Analysis

Methods

The dataset for Arizona allopathic and osteopathic physicians was obtained from the American Medical

Association (AMA) in January 2011. The classifications of practice specialty were based on the two self-identified

specialties listed in the database. This study classifies primary care physicians as those whose specialty includes

family medicine, internal medicine, or pediatrics. Physicians that were not providing direct patient care were

excluded from the analysis, such as administrators (except for those in private practice and HMOs), some

research positions, and government positions not associated with hospitals. Residents in training and physicians

80 years of age or greater were also excluded. The algorithms used to aggregate and classify practice and

specialty types are available upon request.

Communities in Arizona were classified into rural-urban commuting areas (RUCA) using postal zip code

geography to compare differences in the levels of community rurality in the state. The RUCAs are based on US

Census tract data and provide a standard, nationwide classification of rural. RUCA’s were converted to zip code

geographies by the University of Washington (http://depts.washington.edu/uwruca/). The three categories of

9

RUCAs that were used are: urban areas (e.g., Phoenix), large rural town areas (e.g., Payson), and small rural

town areas (e.g., Chinle, Ashfork and Tombstone) (Map 1 and Appendix 7). This three-category classification is

commonly used for health related projects. It divides urban and rural areas approximately the same way as the

US Office of Management and Budget’s metro classification. Population estimates by zip codes were provided by

Nielsen-Claritas, a marketing research company.14

Map 1

Rural Classification by Rural-Urban Commuting Areas that are based on Zip Code Geography in Arizona.

Workforce summaries are presented as total counts and relative counts of currently licensed, direct patient care

physicians. These values likely over estimate the number of practicing, full-time equivalent (FTE) physicians.

County and state population numbers were obtained from the U.S. census. The relative counts are presented as

a rate, the number of physicians per 100,000 population by counties (US Census data) or by RUCA (Nielsen

Claritas data). The US Census and Nielsen Claritas population numbers are not necessarily the same; the relative

counts of physicians at the state-level can be slightly different between estimates based on county and RUCA

geographies.

Results

Table 7 shows the number of primary care, specialist and total physicians (MD and DO) and the location of their

medical school and residency training, categorized as in state or out of state. The important points illustrated in

this table include:

10

66.4% of active physicians in direct patient care in Arizona did not complete either medical school or

residency in Arizona.

10.8% completed medical school in Arizona

30% completed residency in Arizona.

7.2% completed both medical school and residency in Arizona.

A higher proportion of primary care physicians completed medical school (13%) or residency (36.8%) in

the state than did other specialists (9.6% and 26.4%).

Table 7

Arizona Physicians by Specialty and Medical Training

Primary Care Non Primary Care All Physicians

All Direct Care Physicians 4,980 9,175 14,155

No Arizona Training (%) 2,982 (59.9%) 6,421 (70.0%) 9,403 (66.4%)

Arizona Medical School, no Arizona Residency (%)

162 (3.3%) 337 (3.7%) 499 (3.5%)

Arizona Residency, no Arizona Medical School (%)

1,352 (27.1%) 1,877 (20.5%) 3,229 (22.8%)

Both Arizona Medical School and Residency (%)

484 (9.7%) 540 (5.9%) 1,024 (7.2%)

Arizona Medical School +/- Residency (%)

646 (13.0%) 877 (9.6%) 1,523 (10.8%)

Arizona Residency +/- Medical School (%)

1,836 (36.9%) 2,417 (26.3%) 4,253 (30.0%)

Table 8 shows the physicians per population rate for in each category of training history for each of the three

rural categories. This shows the comparative contribution of each category to the physician workforce in these

three categories and allows for inter category comparisons. Important points to notice in this table are:

All three urban/rural categories appear to recruit primary care physicians trained out of state at about

the same rate (44.1-48.6 per 100,000 population)

The more rural a location the fewer specialists there are on a per capita basis, regardless of training

background.

11

Arizona medical students who complete a residency out of state currently contribute very little to the

state’s physician workforce. This is especially true for non-primary care specialists where only 5.4 of the

148/100,000 state total comes from this category). However, those who return to practice primary care

contribute at a higher rate in rural areas than urban (3.7 and 3.5 vs. 2.4 per 100,000). This may be a

reflection of some medical students who desire rural training who need to go out of state to obtain it.

Those who complete a residency in the state but medical school elsewhere remain predominantly in

urban areas to practice. These are probably areas in close proximity to their training programs.

However, this group contributes to rural workforce at a higher rate than Arizona medical students who

leave the state for residency.

Residency training accounts for higher physician rates than medical school training in all areas of the

state. However, the difference between these two options is much more marked in urban areas than

the two rural categories.

It should be noted that these data reflect the training of physicians who are currently practicing in the state and

do not reflect what any cohort of students do. For instance we are not reporting on what proportion of medical

students who are trained in Arizona end up practicing here. It should also be noted that the small contribution

of in-state medical school training to the state’s physician workforce totals reflects the relatively small number

of medical students trained in the state up until the past decade and the time it takes to progress from the start

of medical school to location in practice, which is about a decade.

Table 8

Physicians per 100,000 Population by Specialty and Location of Medical Training in RUCA Categories

Arizona 2010

Physician per 100,000

RUCAs Primary Care

Non Primary Care

All Physicians

All State wide 80.3 148.0 228.4

Urban 84.1 164.0 248.1

Rural, large towns 58.1 74.5 132.7

Rural, small towns 59.7 42.2 101.9

No Arizona Training State wide 48.1 103.6 151.7

Urban 48.6 113.4 162.0

Rural, large towns 44.1 61.6 105.7

Rural, small towns 46.5 35.7 82.2

Arizona Medical School no Arizona Residency

State wide 2.6 5.4 8.1

Urban 2.4 6.0 8.5

Rural, large towns 3.5 2.8 6.2

Rural, small towns 3.7 1.4 5.1

12

Arizona Residency, no Medical School State wide 21.8 30.3 52.1

Urban 24.4 34.5 59.0

Rural, large towns 7.8 8.5 16.4

Rural, small towns 6.1 4.1 10.1

Arizona Medical School and Residency State wide 7.8 8.7 16.5

Urban 8.6 10.0 18.6

Rural, large towns 2.8 1.6 4.4

Rural, small towns 3.5 1.0 4.5

Arizona Medical School +/- Residency State wide 10.4 14.1 24.6

Urban 11.1 16.0 27.1

Rural, large towns 6.2 4.4 10.6

Rural, small towns 7.1 2.4 9.5

Arizona Residency +/- Medical School State wide 29.6 39.0 68.6

Urban 33.1 44.5 77.6

Rural, large towns 10.6 10.2 20.8

Rural, small towns 9.5 5.1 14.6

There are currently 40 physicians practicing in rural Arizona who graduated from an Arizona residency program

between 1990 and 2009. The specialty of these physicians is described in Table 9. Fifty-three percent are family

physicians; 65% in the most rural areas. Time trends show a declining interest in rural practice among graduates

from Arizona residencies. There are 28 primary care physicians in rural Arizona who graduated from an Arizona

residency between 1990-1999 but only 12 who graduated between 2000-2009. Only one internal medicine

physician in rural Arizona graduated from an Arizona residency in the last 10 years.

Table 9

Primary Care Physician Graduates from Arizona Residency Programs, 1990-2009,

Practicing in Rural Areas, by RUCA Category

Rural Large Towns Rural Small Towns Total Rural

# (%) #(%) #(%)

Family Medicine 8 (40) 13 (65) 21 (53)

Internal Medicine 8 (40) 5 (25) 13 (32)

Pediatrics 2 (10) 0 (0) 2 (5)

Internal Medicine/Pediatrics 2 (10) 2 (10) 4 (10)

Total 20 20 40

13

Table 10 explores the age distribution of primary care physicians in each county and rural category by illustrating

the proportion of physicians in ten-year age groups. Rural areas have a slightly larger percentage of active

physicians age 60-79 than the other age groups but only by 1-2 %. The more rural areas do have a smaller

proportion of the two youngest groups, with there being a 10% or greater difference compared to urban.

Several counties have a significantly larger proportion of physicians in the two older age groups; Cochise over

40% and Gila, La Paz and Yavapai over 30%. Several small counties have few or no primary care physicians under

age 50; Santa Cruz and Greenlee.

Table 10

Proportion of Primary Care Physicians by Age Groups for Each County and RUCA

Arizona 2010

Table 11 illustrates the age distribution of non primary care physicians in each county and rural category by

illustrating the proportion of physicians in ten-year age groups. The two more rural categories have a smaller

Proportion of specialists under age 50 and a larger proportion age 60 and above. Forty percent or more of

specialists are age 60 or older in Cochise, Gila, Greenlee, and Santa Cruz counties.

0%10%20%30%40%50%60%70%80%90%

100%

STA

TE (

49

80

)

UR

BA

N (

44

34

)

RU

RA

L LA

RG

E TO

WN

S (2

52

)

RU

RA

L SM

ALL

TO

WN

S (2

94

)

AP

AC

HE

(3

9)

CO

CH

ISE

(6

4)

CO

CO

NIN

O (

14

7)

GIL

A (

41

)

GR

AH

AM

(2

6)

GR

EEN

LEE

(5

)

LA P

AZ

(1

2)

MA

RIC

OP

A (

31

37

)

MO

HA

VE

(1

14

)

NA

VA

JO (

80

)

PIM

A (

96

5)

PIN

AL

(7

7)

SAN

TA C

RU

Z (

17

)

YAV

AP

AI

(15

0)

YUM

A (

99

)

70-79

60-69

50-59

40-49

<40

14

Table 11

Proportion of Non Primary Care Physicians by Age Groups for Each County and RUCA

Arizona 2010

Hospital Sponsorship of Residency Programs in Arizona

Table 12 lists the hospitals that sponsor allopathic residency programs in Arizona and Table 13 lists the hospitals

and other facilities that sponsor osteopathic residency programs. Appendix 1 lists the allopathic residency

programs that are available in the state, Appendix 2 lists the osteopathic programs available in the state, and

Appendix 3 lists the allopathic training programs that are available elsewhere in the U.S but not in Arizona.

Information on allopathic residency programs for Arizona and the U.S. was obtained from the latest Graduate

Medical Education Directory published by the AMA.12 Information on Osteopathic residency programs was

obtained from the AOA web site.13

Some hospitals participate in training residents without actually sponsoring the program they collaborate with.

This collaboration takes the form of having residents on their sites for part of their training. Some hospitals

sponsor their own residencies and participate in other hospitals’ programs. Table 14 lists hospitals in Arizona

that participate in residency programs but do not sponsor them and Table 15 lists other institutions that also

participate in residency training.

0%10%20%30%40%50%60%70%80%90%

100%

STA

TE (

91

75

)

UR

BA

N (

86

44

)

RU

RA

L LA

RG

E TO

WN

S (3

23

)

RU

RA

L SM

ALL

TO

WN

S (2

08

)

AP

AC

HE

(2

7)

CO

CH

ISE

(6

9)

CO

CO

NIN

O (

24

0)

GIL

A (

26

)

GR

AH

AM

(5

)

GR

EEN

LEE

(2

)

LA P

AZ

(2

)

MA

RIC

OP

A (

60

98

)

MO

HA

VE

(1

82

)

NA

VA

JO (

46

)

PIM

A (

19

99

)

PIN

AL

(8

8)

SAN

TA C

RU

Z (

14

)

YAV

AP

AI

(22

6)

YUM

A (

15

1)

70-79

60-69

50-59

40-49

<40

15

Table 12 12

Hospitals Sponsoring Allopathic Residency Programs

Arizona, 2010

Hospital Number of programs

University of Arizona (UMC) 39

Banner Good Samaritan 15

St Joseph’s 15

Maricopa Medical Center 8

University Physicians Hospital Kino 6

Phoenix Children’s Hospital 5

Phoenix Baptist 1

Scottsdale Osborn 1

Tucson Medical Center 1

Total 91

Table 1313

Hospitals and Other Facilities Sponsoring Osteopathic Residency Programs

Arizona, 2010

Institution Number of programs

Kingman Regional Medical Center 2

Sierra Vista Regional Health Center 2

Valley Medical Center, Cottonwood 1

Alta Dermatology, Mesa 1

Desert Dermatology, Peoria 1

Total 8

16

Table 1412

Hospitals participating in but not Sponsoring Allopathic Residency Programs

Arizona, 2010

Hospital Number of programs participating in

Mayo Hospital/Clinic* 26

VA Tucson 21

UPKH 12

VA Phoenix 9

St Joseph’s 6

Phoenix Children’s Hospital 2

Scottsdale Shea 1

Scottsdale Osborn 1

Banner Sun City 1

Total 79

*Mayo hospital operates these residency programs in Arizona but they are sponsored by Mayo Medical

School in Minnesota.

Table 1512

Other Institutions Participating in Allopathic Residency Training in Arizona

Institution Number of programs

Maricopa county medical examiner 1

NIH Phoenix branch 1

Orthopedic clinic associates 1

Trans genomic Institute 1

ASU student health 2

Tucson orthopedic 1

U of A student health 1

University orthopedic specialists 1

Total 9

Appendix 4 lists all hospitals in Arizona by number of beds. Appendices 5 and 6 compare characteristics of

hospitals and hospital systems that sponsor residency programs and those that do not. Data were secured from

the AZ Department of Health Services Uniform Accounting Reports for 2009 and 2010, and updated March

2011.15 Variables that are examined include number of licensed beds, gross patient revenues and annual

patient-bed days. Six hospital systems and five individual hospitals sponsor residency programs across the state.

The Phoenix metropolitan area is served by four of these hospital systems (Abrazo, Banner, Catholic Healthcare

17

West, and Scottsdale Healthcare) and two of the individual hospitals (Maricopa Medical Center and Mayo

Clinic). The Tucson metropolitan area is served by one of the hospital systems (University Medical Center/UPH

Kino) and one of the individual hospitals (Tucson Medical Center). One hospital system, Northern Arizona, and

three hospitals that sponsor residency programs are located in non-metropolitan areas: Kingman Regional

Hospital located in Kingman, Sierra Vista Hospital in Sierra Vista, and Verde Valley Hospital (part of the Northern

Arizona Health System) in Cottonwood. Kingman is the only one licensed as a rural hospital.

The six systems and five individual hospitals that sponsor residency programs currently have 8,715 beds

available. The available bed number ranges from 88 at Sierra Vista to more than 3,000 in the Banner System.

The systems and hospitals together generate over 2 million patient days. Kingman and Sierra Vista each have the

fewest patient days, 36,237 and 17,845 respectively. All others exceed 100,000 Patient Days with Banner having

the most at 843,548.

Kingman, Sierra Vista, and Northern Arizona Health System have gross patient revenue of $559, 282, 675,

$264,555,029, and $877,366,200 respectively. Each of the other systems and hospitals that sponsor residencies

generate gross patient revenue in excess of $1 billion. The range for the latter group is from $1.26 billion at

Tucson Medical Center to more than $9.97 billion at Banner. Mayo generates the highest gross patient revenue

per available bed, $5,481,299, which is more than double the median for all systems and hospitals. Catholic

Healthcare West has the second highest at $4,672,950. Northern Arizona Health System has the lowest at

$2,302,798.

University Medical Center has two facilities affiliated with the state’s allopathic medical school campus in Tucson

and has the highest number of residents at 588; the next highest number is 260 at Banner. Sierra Vista has the

fewest at 16.(Northern Arizona has only 8 but they are in their first years of operation and will have up to 18

when fully operational) All others range from 21 to 230.

Available beds per resident ranges from a high of 47.63 at Northern Arizona and 46.71 in the Abrazo System to

0.87 in the University Medical Center System. The median for all is 6.40 beds per resident.

Similarly the number of patient days per resident is highest at Northern Arizona (29.54) and lowest at University

Medical Center (0.72) and the median for all is 3.97.

Abrazo has the highest gross patient revenue per resident ($112 million) and University Medical Center the

lowest ($3 million). The median is $22.37 million.

Among the systems and individual hospitals that do not sponsor residency programs, the Carondolet System in

Tucson has the highest number of available beds at 945 followed by IASIS Healthcare and John C. Lincoln

systems with 497 and 469 beds respectively. Yuma Regional is the single hospital with the highest number of

beds, 333. Carondolet and Yavapai Regional also have the highest number of patient days at 195,750 and

121,063. Of the single hospitals Yuma has the highest number of patient days at 64,142.

The Carondolet system generates the highest gross patient revenue at over $2.1 million. For single hospitals

Yuma has the highest gross patient revenue at almost $887,689,223.

18

Where Could Other Residency Programs be Located in Arizona?

Among the hospitals systems that sponsor residency programs there is much variation in hospital size measured

by available beds, patient days, and gross patient revenue. Sierra Vista with 88 beds, slightly less than 18

thousand patient days, less than $300,000 in gross patient revenues, and gross patient revenue per available

bed of slightly more than $3 million, sponsors 16 residents.

If 100 beds, 20,000 patient days, $300 thousand in gross patient revenue, and more than $3 million of gross

patient revenue per available bed, was considered the minimum capacity for sponsoring residency programs,

then 16 additional Arizona hospitals could sponsor residency programs. These would be:

Arrowhead, Glendale

Banner Boswell

Banner Baywood

Banner Estrella

Banner Gateway

Chandler Regional

Flagstaff Medical Center

John C. Lincoln, Deer Valley

John C. Lincoln, North Mountain

Mercy Gilbert Medical Center

Mountain Vista Medical Center, Mesa

Northwest Medical Center, Tucson

Scottsdale, Shea

West Valley, Goodyear

West AZ Regional, Bullhead City

Yavapai Regional, Prescott

If using the single criterion of gross patient revenue per available bed, and using the lowest one of these among

hospitals that does sponsor residencies (Tucson Medical Center at $2,227,006), as the minimum, then 18

Arizona hospitals could sponsor residency programs, including:

Banner Thunderbird

Banner Desert Medical Center

Banner Dell Webb

Carondolet St Josephs

Carondolet Holy Cross

Cobre Valley, Globe

Copper Queen, Bisbee

Gilbert, Higley

Scottsdale Healthcare, Shea

19

Kingman Regional

Little Colorado Medical Center, Winslow

Northwest, Oro Valley

Payson Regional

Southeast AZ Medical Center, Douglas

Summit Healthcare Regional, Payson

St Lukes, Tempe

Valley View Medical Center, Fort Mohave

Yavapai Medical Center, Prescott Valley

Yuma Regional

If the number of beds is the sole criteria, then hospitals with 100 beds or more are potential and these are listed

in Appendix 7.

Survey of Hospitals

Methods

An electronic survey was sent to 57 hospital Chief Executive Officers (CEOs). Responses were received from 39

for a response rate of 68%. Of hospitals with 50+ beds there were 51 in the universe of which 35 responded for a

response rate of 70 %. All (100%) of the hospital systems responded.

The survey questions were divided into two categories; those that currently have residency programs and those

that do not. For the first group questions included number and specialty of programs, number of residents, and

plans for expansion or reduction of positions or programs. For the second group questions included: previous

attempts at establishing programs and in what specialties, or if no previous attempts, reasons for not doing so,

and what information or assistance would be needed to plan for establishing programs.

Of the hospitals not sponsoring residency programs, none of the directors at the present time are thinking about

doing so except at Yuma Regional, which is in the process of establishing 4 primary care residencies. Seven

responses indicated that they had, in the past, considered establishing residencies. The reasons for not doing so

included:

Issues and uncertainties related to direct medical education and indirect medical education funding by

Medicare.

Financial concerns.

Lack of Board interest in the GME process at a community hospital.

A perceived need to partner with another organization.

Not enough physician support of the project.

20

In answer to the question “What would be useful to you if you were to consider whether or not to sponsor

residencies?” the answers were:

Information on the costs associated with residencies and the reimbursement.

Accreditation requirements associated with such a commitment.

In answer to the question “what factors will most affect a decision whether or not to sponsor a residency

program?” the answers were:

Cost and reimbursement.

Resources, i.e. time, money, and staffing.

Ability to partner with another organization to fill in gaps in our institution

Survey of Community Health Centers

Other institutions such as community health centers (CHCs) can sponsor residency programs but the way

programs are funded through Medicare and Medicaid, with reimbursement going to hospitals, makes this

difficult. The Affordable Care Act appropriates money through the Health Resources and Services Administration

for CHCs to plan for and operate residencies, with funding going directly to the health centers. This potentially

offers a small number of CHC’s the opportunity to sponsor residencies.

The staff at the Arizona Association of Community Health Centers was asked to survey directors of the

community health centers in the state to ascertain if any are considering sponsoring residency programs.

Currently, two report that they are; one in Tucson and one in Flagstaff. However, only the CHC in Flagstaff,

North Country CHC, is actively working toward establishing a program. The North Country CHC has plans to start

a family medicine residency for 4 residents per year to start in July 2013.

Remaining Questions

There are several questions regarding medical education in the state and its impact on the Arizona physician

workforce that are pertinent for planning purposes and that currently are unanswered.

1. What proportion of medical students trained in Arizona eventually practice in the state?

a. Does this proportion vary between those who received residency training in Arizona and

elsewhere?

b. Does this proportion vary by location of residency training (rural vs. urban)?

2. What proportion of residents trained in Arizona will stay and practice in the state following completion

of residency?

a. Does this proportion vary between those who grew up in Arizona and those who did not?

b. Does this proportion vary by location of medical school training (in state vs. out of state)?

21

It is commonly believed that those most likely to practice in the state, in order of likelihood are:

Those who grew up in Arizona and who complete both medical school and residency in Arizona

Those who grew up in Arizona who complete medical school out of state and residency in state

Those who did not grow up in Arizona who complete residency in state

Those who grew up in Arizona who complete medical school in state and residency out of state

However, data to support these beliefs are not currently available and will not be provided by this study.

Prospective or retrospective cohort studies would be needed to explore these issues.

3. Given the concerns raised by community hospital CEO’s, what real incentives exist and what incentives

can be created to move CEO’s and hospital boards to develop new residency programs?

Recommendations From the Advisory Group

The final component of this project involved presenting the findings to an advisory group of stakeholders to seek

their input on the analyses and to develop ideas for addressing the need for more residency training in Arizona.

A half-day meeting was held at the University of Arizona College of Medicine, Phoenix Campus, on June 28,

2011. Appendix 9 lists those who attended.

The data in the report were presented and discussed and then time was devoted to brainstorming about

possible approaches. The recommendations made by the Advisory Group can be divided into two categories;

those pertaining to workforce tracking, analysis and technical assistance; and ideas for potential state policies.

Work Force Tracking, Analysis and Technical Assistance

The Advisory Group recommended to:

1. Establish a state health care workforce commission.

a. Have the AHEC convene the advisory group periodically until such a commission is established.

b. Explore sources of funding from foundations.

c. Include the Bureau of Primary Care at the Arizona Department of Health Services.

2. Look for any evidence that shows that residencies in a hospital are associated with higher quality.

3. Develop a pool of consultants on GME funding, accreditation standards, practical aspects of starting a

program.

4. Bring to AZ someone from a CHC-sponsored program that currently receives CMS GME funding so they

can educate us on how that is achieved.

5. Explore with the Colleges of Medicine the potential for 1-2 programs in collaboration with rural

hospitals. (1-2 programs are describe in Appendix 10)

6. Engage the business community by involving the Chamber of Commerce. Demonstrate to them the

economic impact of residency training.

7. Have regional AHECs track rotations from medical students from out of state.

22

Policies to Increase the Number of Residency Programs

The Advisory Group came up with some suggested policy actions, including:

1. Creating incentives to start programs for hospitals that do not currently sponsor programs.

2. Developing additional incentives to start primary care residency programs, especially in rural areas.

3. Concentrating on the Banner system and possibly meeting with their leadership.

4. Meeting with the Arizona congressional delegation to discuss modification of the GME funding cap

rules for new programs to advocate for more time to phase in a series of programs at new hospitals

before they are capped. (More than the current three year period)

5. Emphasizing to policy makers that quality of life in Arizona affects recruitment and retention of

physicians.

6. Developing a source of bridge funds that can be used to support a program until federal GME

funding kicks in.

23

References

1. AAMC. 2011 State Physician Workforce Data Release. March 2011.

https://www.aamc.org/download/181238/data/state_databook_update.pdf

2. Eng HJ, Tabor J, Hughes A. Arizona Rural Health Workforce Trend Analysis. University of Arizona Rural

Health Office, 2011.

3. U.S. Dept of Health & Human Services, Health Resources and Services Administration. Shortage Designation: Health Professional Shortage Areas & Medically Underserved Areas/Populations. June 2011 http://bhpr.hrsa.gov/shortage/

4. Office of Management and Budget. Update of Statistical Area Definitions and Guidance on Their Uses. Washington, DC. 2009. http://www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf

5. Rural Health Research Center. RUCA Data. University of Washington, Seattle. http://depts.washington.edu/uwruca/ruca-uses.php

6. Jonas HS, Etzel SI, Barzansky B. Undergraduate medical education. JAMA 1989;262:1011-1019. 7. Medical Schools in the United States. JAMA 2000;284:1149-1157. 8. Medical Schools in the United States, 2009-2010. JAMA 2010;1247-1254.

9. Etzel SI, Egan RL, Shevrin MP, Rowley BD. Graduate medical education in the United States. JAMA

1989;262:1029-1037.

10. Graduate Medical Education. JAMA 2000; 284:1159-1172.

11. Brotherton SE, Etzel SI. Graduate Medical Education 2009-2010. JAMA 2010;304:1255-1270.

12. AMA. Graduate Medical Education Directory 2010-2011. Chicago 2010

13. AOA. Approved Internships and residencies.

http://opportunities.osteopathic.org/search/search.cfm?searchType=1&CFID=1481109&CFTOKEN=cd70

e784d6364d16-243EABFB-FDFF-13FB-

692F5C8F3E08FB20&jsessionid=f030ecbe1d1ef6943d5a16183d6481569742

14. Nielsen. SiteReport. http://www.claritas.com/sitereports/Default.jsp

15. AZ Department of Health Services, Uniform Accounting Reports 2010, updated March 2011.

http://www.azdhs.gov/plan/crr/cr/hospitals.htm

24

Appendix 1

Allopathic Residency Programs in Arizona, 2010 12

Number of Programs in Arizona (number of programs in U.S.)

Capacity, number of trainees approved for

Primary Care

Family medicine 6 (459) 141

Geriatrics 3 (141) 9

Internal medicine 6 (383) 302

Internal medicine/Pediatrics 1 (80) 24

Pediatrics 3(195) 145

Total 19 (1258) 621

Non Primary Care

Anesthesiology 2 (130) 45

Dermatology 1 (109) 6

Emergency medicine 3 (143) 108

Medical toxicology 1 4

Sports medicine 2 (97) 4

Hospice and palliative care 1 1

Cardiovascular disease 3 (177) 38

Clinical cardiac electrophysiology 1 (95) 1

Endocrinology 2 (122) 9

Gastroenterology 3 (154) 25

Hematology and oncology 2 (127) 10

Infectious diseases 1 (141) 5

Interventional cardiology 3 (130) 6

Nephrology 1 (139) 6

Pulmonary medicine 1 (25) 2

Pulmonary and critical care 2 (130) 16

Rheumatology 1 (109) 4

Transplant hepatology 1 2

Molecular genetic pathology 1 1

Neurological surgery 2(97) 34

Endovascular surgical neuroradiology

1 2

Neurology 4 (124) 51

Child neurology 1 (69) 3

Clinical neurophysiology 2 (91) 4

Vascular neurology 2 2

Obstetrics and gynecology 3 (247) 83

Ophthalmology 2 (118) 12

Orthopedic surgery 2 (153) 35

25

Adult reconstructive orthopedics 1 1

Orthopedic sports medicine 1 (78) 2

Otolaryngology 1(104) 10

Pain Medicine 1(92) 1

Pathology—Anatomical and clinical

2(150) 26

Hematology 1 (79) 1

Neuropathology 1(35( 1

Pediatric emergency medicine 1 (46) 6

Pediatric endocrinology 2 (67) 6

Pediatric hematology/oncology 1 (66) 6

Pediatric pulmonology 1 (47) 3

Pediatrics/ Emergency medicine combined

1 (3) 10

Plastic surgery 1 (87) 4

Psychiatry 4 (181) 106

Child psychiatry 2 (121) 7

Radiation oncology 1 (80) 6

Radiology 3 (188) 53

Neuroradiology 2 (86) 10

Pediatric radiology 1 (43) 3

Vascular and interventional radiology

1 (93) 1

Surgery, general 5 (251) 160

Surgery, critical care 1 (90) 2

Vascular surgery 3(96) 9

Thoracic surgery 1 (79) 2

Transitional year 2 (124) 18

Urology 2 (118) 14

Total 94 972

Primary care and non primary care Total

113*** 1593

** Can be under either Internal Medicine or Family Medicine

*** Does not total 114 as in Table 6 because Mayo ended its family medicine program which is included in Table

6 but not in Appendix 1

26

Appendix 2

Osteopathic Residency Programs in Arizona

Number of programs Number of slots

Dermatology 2 7

Emergency medicine 1 16

Family medicine 2 23

Internal medicine 2 30

Total 7 76

Appendix 3

Allopathic Residency Programs Not Available in Arizona 2010

(Numbers of programs available in the U.S.)

Allergy and immunology (71)

Critical care medicine (49)

Adult cardiothoracic anesthesiology (38)

Pediatric anesthesiology (46)

Colon and rectal surgery (45)

Dermatopathology (54)

Procedural dermatology (42)

Medical genetics

Nuclear medicine (56)

Hand surgery (55)

Blood banking (46)

Cytopathology (85)

Selective pathology (56)

Neonatal medicine (97)

Pediatric emergency medicine (21)

Pediatric cardiology (47)

Pediatric critical care (61)

Pediatric gastroenterology (51)

Pediatric infectious diseases (61)

Pediatric nephrology (37)

Physical medicine and rehabilitation (79)

Preventive medicine (71)

Geriatric psychiatry (60)

Pediatric surgery (34)

27

Appendix 4

Hospitals in Arizona by Number of Beds

HOSPITAL CITY SYSTEM BEDS (Licensed)

300 Beds or more

St. Josephs Hospital & Med. Ctr. Phoenix CHW 738

Maricopa Med. Ctr. Phoenix 718

Banner Good Samaritan Phoenix Banner 662

Banner Desert Med. Ctr. Mesa Banner 649

Tucson Medical Center Tucson 628

Banner Thunderbird Glendale Banner 513

Carondolet St. Josephs Tucson Carondelet 478

Scottsdale Healthcare-Shea Scottsdale Scottsdale Health 433

Banner Boswell Sun City Banner 430

Banner Del Webb Sun City West Banner 404

Carondolet St. Mary’s Tucson Carondelet 402

University Medical Ctr. Tucson UMC 355

Phoenix Childrens Phoenix 345

Banner Baywood Mesa Banner 340

Scottsdale Healthcare-Osborn Scottsdale Scottsdale Health 337

Yuma Regional Med. Ctr. Yuma 333

Northwest Med. Ctr. Tucson Community Hlth. 300

200-299 Beds

Flagstaff Medical Center Flagstaff Northern AZ Hlth. 271

John C. Lincoln North Mt. Phoenix JCL 266

Mayo Clinic Phoenix 244

Phoenix Baptist /AZ Heart Phoenix Abrazo 236

Kingman Regional Kingman 235

Maryvale Hospital Phoenix Abrazo 232

St. Luke’s Med. Ctr. Phoenix IASIS 232

Chandler Regional Chandler CHW 225

Arrowhead Hospital Glendale Abrazo 220

Banner Estrella Phoenix Banner 214

Mercy Gilbert Med. Ctr. Gilbert CHW 206

John C. Lincoln Deer Valley Phoenix JCL 204

100 TO 199 BEDS

UPH at Kino Tucson UMC 197

Casa Grande Regional Casa Grande 187

28

Havasu Regional Med. Ctr Havasu City 181

Mountain Vista Med. Ctr. Mesa IASIS 178

Banner Gateway Gilbert Banner 165

West Valley Hospital Goodyear Abrazo 164

Northwest Med. Ctr. Oro Valley Community Hlth. 144

West AZ Regional Med. Ctr. Bullhead City 139

Paradise Valley Hospital Phoenix Abrazo 136

Yavapai Regional Med. Ctr. Prescott Yavapai Regional 136

Verde Valley Med. Ctr. Cottonwood Northern AZ Hlth. 110

AZ Regional Medical Center Mesa 103

LESS THAN 100 BEDS

Sierra Vista Regional Sierra Vista 88

Tempe St. Luke’s Tempe IASIS 87

Summit Healthcare Reg. Med. Ctr. Show Low 81

Hualapai Mt. Med. Ctr. Kingman 70

Scottsdale Healthcare-Thompson Peak Scottsdale Scottsdale Health 64

Mt. Graham Reg. Med. Ctr. Safford 55

Yavapai Reg. Med. Ctr. East Prescott Valley Yavapai Regional 50

Payson Regional Med. Ctr Payson 44

La Paz Regional Parker 39

Banner Ironwood San Tan Valley Banner 36

Carondolet Holy Cross Nogales Carondelet 25

Cobre Valley Hospital Globe 25

Little Colorado Med. Ctr Winslow 25

Page Hospital Page Banner 25

Sage Memorial Ganado 25

Southeast AZ Med. Ctr. Douglas 25

Northern Cochise Community Willcox 24

Benson Hospital Benson 22

Gilbert Hospital Higley 19

Wickenberg Community Wickenberg 19

White Mt. Reg. Med. Ctr. Springerville 16

Copper Queen Hospital Bisbee 14

29

Appendix 5

Available beds, patient days, and $1M gross patient revenue/resident

Systems/Hospitals with Residency Programs

SYSTEM/HOSPITAL #

Hosps Avail.

Beds(1) Pat

Days(1) Gross Pat.

Rev.(1) Rsidnts Avail.

Beds/Res. Pat

days/Res $1m

GPR/Res. GPR/Avail.

Bed

ABRAZO SYSTEM 5 981 154,802 $2,354,951,000 21 46.71 14.74 112.14 $2,400,562

BANNER SYSTEM 10 3,156 843,548 $9,977,111,119 260 12.14 8.89 38.37 $3,161,315

CATHOLIC HEALTHCARE WEST 3 1,175 313,227 $5,490,716,674 225 4.72 3.81 17.85 $4,672,950

NORTHERN AZ HEALTH SYSTEM 2 381 86,255 $877,366,200 8 47.63 29.54 109.67 $2,302,798

SCOTTSDALE HEALTHCARE SYSTEM 3 834 178,195 $2,573,856,613 25 33.36 19.53 102.95 $3,086,159

UNIV. MED. CENTER SYSTEM 2 514 154,692 $1,813,936,242 588 0.87 0.72 3.08 $3,529,059

Kingman Regional

160 36,237 $559,282,675 25 6.40 3.97 22.37 $3,495,517

Maricopa Med. Ctr. 614 134,691 $1,585,631,011 230 2.67 1.60 6.89 $2,582,461

Mayo Clinic 244 65,100 $1,337,437,000 150 1.63 1.19 8.95 $5,481,299

Sierra Vista Regional 88 17,845 $264,455,029 16 5.50 3.06 16.53 $3,005,171

Tucson Medical Center 568 145,615 $1,264,939,507 45 12.62 8.87 28.11 $2,227,006

TOTAL (last 4 cols. are averages) 8,715 2,130,207 $28,099,683,070 1593 24.75 14.24 56.93 $3,224,290

MEDIAN 514 134,691 $1,337,437,000 45 6.40 3.97 22.37 $3,086,159

30

Appendix 6

Available Beds, Patient Days, Gross Patient Revenue & Gross Patient Revenue/Available Bed

System/Hospitals without Residency Programs

SYSTEM/HOSPITAL # Hosps Avail. Beds(1) Pat Days(1) Gross Pat. Rev.(1) GPR/Avail. Bed

CARONDOLET SYSTEM 4 945 195,750 $2,178,246,945 $2,305,023

COMMUNITY HEALTH SYSTEM 2 414 69,009 $1,483,624,294 $3,583,634

IASIS SYSTEM 3 497 74,445 $1,309,338,000 $2,634,483

JOHN C LINCOLN SYSTEM 2 469 121,063 $1,860,090,382 $3,966,078

YAVAPAI REGIONAL SYSTEM 2 180 35,770 $567,725,103 $3,154,028

AZ Regional Medical Center 103 10,694 $145,972,525 $1,417,209

Benson Hospital 19 1,404 $18,695,683 $983,983

Casa Grande Regional 187 33,975 $367,175,903 $1,963,508

Cobre Valley Hospital 25 5,041 $57,476,791 $2,299,072

Copper Queen Hospital 14 1,752 $43,068,918 $3,076,351

Gilbert Hospital 19 5,574 $158,095,207 $8,320,800

Havasu Regional Med. Ctr 181 26,476 $378,119,000 $2,089,055

Hualapai Mt. Med. Ctr. 70 7,162 $85,701,000 $1,224,300

La Paz Regional 35 3,854 $63,016,022 $1,800,458

Little Colorado Med. Ctr 25 3,889 $71,169,394 $2,846,776

Mt. Graham Reg. Med. Ctr. 55 9,292 $117,941,253 $2,144,386

Northern Cochise Commty 24 3,837 $37,727,555 $1,571,981

Payson Regional Med. Ctr 44 8,184 $229,082,374 $5,206,418

Sage Memorial 25 3,198 $21,199,678 $847,987

Southeast AZ Med. Ctr. 25 1,736 $246,325,921 $9,853,037

Summit Healthcare Reg. Med. Ctr. 81 11,955 $256,126,484 $3,162,055

Valley View Med. Ctr. 66 16,129 $225,209,000 $3,412,258

West AZ Regional Med. Ctr. 139 27,435 $623,610,930 $4,486,410

White Mt. Reg. Med. Ctr. 16 1,563 $25,297,565 $1,581,098

Wickenberg Community 19 2,051 $22,256,234 $1,171,381

Yuma Regional Med. Ctr. 333 64,142 $887,689,223 $2,665,733

TOTAL (last col. is average) 4,234 816,839 $12,953,434,347 $2,880,278

MEDIAN 66 9,292 $225,209,000 $1,800,458

31

Appendix 7

Hospitals in Arizona That Do Not Sponsor Residency Programs by Number of Beds**

HOSPITAL CITY SYSTEM BEDS (Licensed)

Banner Desert Med. Ctr. Mesa Banner 649

Banner Thunderbird Glendale Banner 513

Carondolet St. Josephs Tucson Carondelet 478

Scottsdale Healthcare-Shea Scottsdale Scottsdale Health 433

Banner Boswell Sun City Banner 430

Banner Del Webb Sun City Wst. Banner 404

Carondolet St. Marys Tucson Carondelet 402

Banner Baywood Mesa Banner 340

Yuma Regional Med. Ctr. Yuma 333

Northwest Med. Ctr. Tucson Community Health. 300

200-299 Beds

Flagstaff Medical Center Flagstaff Northern AZ Health. 271

John C. Lincoln North Mt. Phoenix JCL 266

Maryvale Hospital Phoenix Abrazo 232

St. Lukes Med. Ctr. Phoenix IASIS 232

Chandler Regional Chandler CHW 225

Arrowhead Hospital Glendale Abrazo 220

Banner Estrella Phoenix Banner 214

Mercy Gilbert Med. Ctr. Gilbert CHW 206

John C. Lincoln Deer Valley Phoenix JCL 204

100 TO 199 BEDS

Casa Grande Regional Casa Grande 187

Havasu Regional Med. Ctr Havasu City 181

Mountain Vista Med. Ctr. Mesa IASIS 178

Banner Gateway Gilbert Banner 165

West Valley Hospital Goodyear Abrazo 164

Northwest Med. Ctr. Oro Valley Community Health. 144

West AZ Regional Med. Ctr. Bullhead City 139

Paradise Valley Hospital Phoenix Abrazo 136

Yavapai Regional Med. Ctr. Prescott Yavapai Regional 136

AZ Regional Medical Center Mesa 103

50-99 BEDS

Tempe St. Lukes Tempe IASIS 87

Summit Healthcare Reg. Med. Ctr. Show Low 81

Hualapai Mt. Med. Ctr. Kingman 70

Scottsdale Healthcare-Thompson Peak Scottsdale Scottsdale Health 64

Mt. Graham Reg. Med. Ctr. Safford 55

Yavapai Reg. Med. Ctr. East Prescott Valley Yavapai Regional 50

** Did not include hospitals with under 50 beds.

32

Appendix 8

List of Town and Cities in Arizona and their Ruralness Classifications

Town-City County Zip Code-RUCA

Ajo Pima Small rural town

Ak-Chin Village Pinal Urban

Amado Santa Cruz Urban

Apache Junction Pinal Urban

Arizona City Pinal Small rural town

Arizona Village Mohave Small rural town

Ash Fork Yavapai Small rural town

Avondale Maricopa Urban

Avra Valley Pima Urban

Bagdad Yavapai Small rural town

Benson Cochise Small rural town

Big Park Yavapai Small rural town

Bisbee Cochise Small rural town

Bitter Springs Coconino Small rural town

Black Canyon City Yavapai Urban

Blackwater Pinal Small rural town

Bluewater La Paz Small rural town

Bouse La Paz Small rural town

Buckeye Maricopa Urban

Bullhead City Mohave Small rural town

Burnside Apache Small rural town

Cameron Coconino Small rural town

Camp Verde Yavapai Small rural town

33

Town-City County Zip Code-RUCA

Canyon Day Gila Small rural town

Carefree Maricopa Urban

Casa Grande Pinal Large rural town

Casas Adobes Pima Urban

Catalina Pima Urban

Catalina Foothills Pima Urban

Cave Creek Maricopa Urban

Chandler Maricopa Urban

Chilchinbito Navajo Small rural town

Chinle Apache Small rural town

Chino Valley Yavapai Urban

Chuichu Pinal Large rural town

Cibecue Navajo Small rural town

Cibola La Paz Urban

Cienega Springs La Paz Small rural town

Clarkdale Yavapai Large rural town

Claypool Gila Large rural town

Clifton Greenlee Small rural town

Colorado City Mohave Small rural town

Congress Yavapai Urban

Coolidge Pinal Small rural town

Cordes Lakes Yavapai Urban

Cornville Yavapai Small rural town

Corona de Tucson Pima Urban

Cottonwood Yavapai Large rural town

Dennehotso Apache Small rural town

34

Town-City County Zip Code-RUCA

Desert Hills Mohave Large rural town

Dewey-Humbolt Yavapai Urban

Dilkon Navajo Small rural town

Dolan Springs Mohave Large rural town

Douglas Cochise Large rural town

Drexel Heights Pima Urban

Dudleyville Pinal Small rural town

Duncan Greenlee Small rural town

Eagar Apache Small rural town

East Fork Navajo Small rural town

East Sahuarita Pima Urban

Ehrenberg La Paz Large rural town

El Mirage Maricopa Urban

Elgin Santa Cruz Small rural town

Eloy Pinal Small rural town

First Mesa Navajo Small rural town

Flagstaff Coconino Urban

Florence Pinal Large rural town

Flowing Wells Pima Urban

Fort Defiance Apache Small rural town

Fortuna Foothills Yuma Urban

Fountain Hills Maricopa Urban

Fredonia Coconino Small rural town

Gadsden Yuma Urban

Ganado Apache Small rural town

Gila Bend Maricopa Urban

35

Town-City County Zip Code-RUCA

Gilbert Maricopa Urban

Gisela Gila Large rural town

Glendale Maricopa Urban

Globe Gila Large rural town

Gold Canyon Pinal Urban

Golden Valley Mohave Large rural town

Goodyear Maricopa Urban

Grand Canyon Village Coconino Small rural town

Greasewood Navajo Small rural town

Green Valley Pima Urban

Guadalupe Maricopa Urban

Hayden Gila Small rural town

Holbrook Navajo Small rural town

Hotevilla-Bacavi Navajo Small rural town

Houck Apache Small rural town

Huachuca City Cochise Large rural town

Jeddito Navajo Small rural town

Jerome Yavapai Large rural town

Kachina Village Coconino Urban

Kaibab Mohave Small rural town

Kaibito Coconino Small rural town

Kayenta Navajo Small rural town

Keams Canyon Navajo Small rural town

Kearny Pinal Small rural town

Kingman Mohave Large rural town

Kykotsmovi Village Navajo Small rural town

36

Town-City County Zip Code-RUCA

Lake Havasu City Mohave Large rural town

Lake Montezuma Yavapai Small rural town

LeChee Coconino Small rural town

Leupp Coconino Urban

Litchfield Park Maricopa Urban

Littletown Pima Urban

Lukachukai Apache Small rural town

Mammoth Pinal Urban

Many Farms Apache Small rural town

Marana Pima Urban

Maricopa Pinal Urban

Mayer Yavapai Urban

McNary Apache Small rural town

Mesa Maricopa Urban

Mesquite Creek Mohave Small rural town

Miami Gila Large rural town

Moenkopi Coconino Small rural town

Mohave Valley Mohave Small rural town

Mojave Ranch Estates Mohave Small rural town

Morenci Greenlee Small rural town

Mountainaire Coconino Urban

Munds Park Coconino Small rural town

Naco Cochise Small rural town

Nazlini Apache Small rural town

New River Maricopa Urban

Nogales Santa Cruz Large rural town

37

Town-City County Zip Code-RUCA

Oracle Pinal Urban

Oro Valley Pima Urban

Page Coconino Small rural town

Paradise Valley Maricopa Urban

Parker La Paz Small rural town

Parks Coconino Small rural town

Patagonia Santa Cruz Small rural town

Paulden Yavapai Urban

Payson Gila Large rural town

Peach Springs Mohave Large rural town

Peeples Valley Yavapai Urban

Peoria Maricopa Urban

Peridot Gila Small rural town

Phoenix Maricopa Urban

Picture Rocks Pima Urban

Pima Graham Large rural town

Pine Gila Large rural town

Pinetop-Lakeside Navajo Small rural town

Pinon Navajo Small rural town

Pirtleville Cochise Large rural town

Pisinemo Pima Small rural town

Poston La Paz Small rural town

Prescott Yavapai Urban

Prescott Valley Yavapai Urban

Quartzsite La Paz Small rural town

Queen Creek Maricopa Urban

38

Town-City County Zip Code-RUCA

Queen Valley Pinal Urban

Red Mesa Apache Small rural town

Rio Verde Maricopa Urban

Rock Point Apache Small rural town

Rough Rock Apache Small rural town

Round Rock Apache Small rural town

Sacaton Pinal Small rural town

Safford Graham Large rural town

Sahuarita Pima Urban

Salome La Paz Small rural town

San Carlos Gila Small rural town

San Luis Yuma Urban

San Luis Pima Small rural town

San Manuel Pinal Small rural town

Santa Rosa Pima Small rural town

Sawmill Apache Small rural town

Scottsdale Maricopa Urban

Second Mesa Navajo Small rural town

Sedona Coconino Small rural town

Seligman Yavapai Small rural town

Sells Pima Small rural town

Shonto Navajo Small rural town

Show Low Navajo Small rural town

Shungopavi Navajo Small rural town

Sierra Vista Cochise Large rural town

Snowflake Navajo Small rural town

39

Town-City County Zip Code-RUCA

Somerton Yuma Urban

Sonoita Santa Cruz Small rural town

South Tucson Pima Urban

Spring Valley Yavapai Urban

Springerville Apache Small rural town

Stanfield Pinal Urban

Star Valley Gila Large rural town

Steamboat Apache Small rural town

Stotonic Pinal Small rural town

Strawberry Gila Large rural town

Summit Pima Urban

Sun City Maricopa Urban

Sun City West Maricopa Urban

Sun Lakes Maricopa Urban

Sun Valley Navajo Small rural town

Superior Pinal Urban

Surprise Maricopa Urban

Swift Trail Junction Graham Large rural town

Tacna Yuma Urban

Tanque Verde Pima Urban

Taylor Navajo Small rural town

Teec Nos Pos Apache Small rural town

Tempe Maricopa Urban

Thatcher Graham Large rural town

Three Points Pima Urban

Tolleson Maricopa Urban

40

Town-City County Zip Code-RUCA

Tombstone Cochise Small rural town

Tonalea Coconino Small rural town

Tonto Basin Gila Large rural town

Top-of-the-World Gila Large rural town

Tortolita Pima Urban

Tsaile Apache Small rural town

Tuba City Coconino Small rural town

Tubac Santa Cruz Small rural town

Tucson Pima Urban

Tucson Estates Pima Urban

Tusayan Coconino Small rural town

Vail Pima Urban

Wellton Yuma Urban

Wenden La Paz Small rural town

Whetstone Cochise Large rural town

Whiteriver Navajo Small rural town

Wickenburg Maricopa Urban

Wilhoit Yavapai Urban

Willcox Cochise Small rural town

Williams Coconino Small rural town

Williamson Yavapai Urban

Willow Valley Mohave Small rural town

Window Rock Apache Small rural town

Winkelman Gila Small rural town

Winslow Navajo Small rural town

Winslow West Coconino Urban

41

Town-City County Zip Code-RUCA

Yarnell Yavapai Urban

Young Gila Large rural town

Youngtown Maricopa Urban

Yuma Yuma Urban

Source: Rural Urban Commuting Areas (RUCA) Classification. Population estimates provided by Nielsen-Claritas

42

Appendix 9

Advisory Group Members

Wendy Armendariz, Director of Outreach & Enrollment/SEARCH (Student/Resident Experiences and Rotations in Community Health) and the Community Development Program for the Arizona Association of Community Health Centers Conrad J. Clemens, MD, MPH, Interim, DIO & Associate Dean for Graduate Medical Education, University of Arizona College of Medicine, Tucson Sean Clendaniel, Executive Director, Northern Arizona Area Health Education Center Gail E. Emrick, MPH, Executive Director, Southeast Arizona Area Health Education Center Michael Grossman, MD, MACP, Associate Dean for GME, University of Arizona College of Medicine, Phoenix Beth Lazare, Governors Office, Policy Advisor for Health and Human Services Laurie Liles, President and Chief Executive Officer, Arizona Hospital and Healthcare Association John C. McDonald, RN, MS, CPHQ, Chief Executive Officer, Arizona Association of Community Health Centers Thomas E. McWilliams, D.O., FACOFP, Interim Dean, A.T. Still University School of Osteopathic Medicine in Arizona Ellen Owens-Summo, M.Ed., DTR, Director of Health Education and Professional Development, Greater Valley Area Health Education Center Sally Reel, PhD, RN, FNP, BC, FAAN, FAANP, Director, Arizona AHEC Howard M. Shulman, DO, FACP, FACOI, Associate Dean Postdoctoral Education, Midwestern University Osteopathic Postdoctoral Training Institution (MWU/OPTI), Chair Osteopathic Graduate Medical Education Committee, Associate Professor, Midwestern University Arizona College of Osteopathic Medicine Project Team

Doug Campos-Outcalt, M.D., M.P.A.

Joe Tabor, Ph.D., M.P.H.

Phil Lopes, M.A.

Ed Paul, M.D.

43

Appendix 10

“1-2” or Rural Training Track” Programs

In considering potential sites for residency training in Arizona, the specialty of Family Medicine supports a 1-2

model or Rural Training Track model for rural areas. This model allows the first year of training to occur in an

academic teaching center or large teaching community hospital followed by the next two years of training at a

geographically distant, rural clinical site.

Participation in this model would allow small hospitals to experience residency education without committing to

the large financial investment, including the employment of informed GME staff that is required for the

development of new GME programs. These small hospitals would benefit from the recruitment of many of the

residents assigned to their institution and in some instances, after experiencing the inclusion of clinical teaching

in their environment, may spark a commitment to sponsor their own programs. The 1-2 track model for Family

Medicine does not exist in any current Family Medicine program in Arizona but it is a means to expand the

numbers of primary care residency positions and to expose more residents to rural Arizona communities.

Approximately 30 Rural Training Track programs exist currently in the U.S. and the most recent survey shows a

75% recruitment rate of graduates to rural sites. 11