The Health Professions Resource Center (HPRC) obtains a licensing database each year for physicians from the Texas Medical Board (TMB). This is a "Master" file that contains a record for each physician who currently holds a Texas license; this is an unedited file containing many more records than are eventually reported by HPRC (98,353 in 2008). HPRC then edits the Master database substantially to create databases for Texas Active Direct Patient Care (DPC) Physicians and Texas Active Primary Care (PC) Physicians, which are then used to create the supply tables that are posted on the HPRC website. Because of this extensive editing, the Physician numbers reported by HPRC are usually different than those reported by TMB or other organizations. Below is documentation of the steps taken by HPRC in the file editing process.
Removal of “out-of-state” records:
HPRC removes those records that indicate an out-of-state Practice Address, or, if no Practice Address is available, those records with an out-of-state Mailing Address. Out of 98,353 records on the 2008 Master file, 32,589 were removed for having out-of-state addresses. This “Texas” file is then sent to the Geographic Information Systems (GIS) unit of the Center for Health Statistics for geocoding, which assigns a mailing and a practice county name, based on the mailing and practice addresses, to each record. The file obtained from TMB does already include a mailing county, but analyses have shown that there are often a substantial number of errors; and, no practice county name is provided by TMB. This geocoding process began in 2002; the files were assigned county names by a different method prior to that (see “New Procedures” below).
Removal of Inactive records:
The Physician file includes a field for Registration Status Code, which includes these possible entries (as of 2008):
AC - Active
ACN - Active Not Practicing
BC - Bad Credit – Prior to 3/7/2005
CC - Considered Canceled (Replaced CN)
CN - Canceled Non Payment
CNB - Canceled Non Payment by Board (Replaced CC & CN)
CP - Complete, Pending Reinstatement
CR - Canceled by Request
CRB - Canceled by Request by Board (Replaced CRB)
CTL - CME Temporary License
DC - Deceased
DQ - Delinquent Non Payment
IA - Inactive Prelim to Becoming CR
LI - License Issued
LD - Loan Default
NA - Not Active
NR - Non Standard Retired Affidavit
PPD - Payment Processing Delay
PR - Pending Reinstatement
SBA - Suspended by the Board-Active
TI - Texas License Issued
TR - Texas Retired
VC - Voluntary Charity Care Only
HPRC considers a record to be Active if it has one of the following codes: AC, ACN, BC, CP, CTL, DQ, LD, LI, PR, or TI. In 2008, 15,402 records were removed from the file for having an Inactive Registration Status Code.
In addition, each year there are a small number of records that indicate in some way that the physician is Inactive even if the Registration Status Code is Active, and these records are considered to be Inactive and are removed. These records usually have entries in either the practice or mailing address field such as “Not in Practice,” “X:NIP,” “X:NO”, “Z:NIP”, “NIP” or “RETIRED.” There were 169 such records in 2008.
Also, records that indicate “Locum Tenens” in either the practice or mailing address field are removed. There were 62 such records in 2008.
These edits result in a file considered to be all of the "Texas Active Physicians."
Determination of Direct Patient Care Physicians:
Prior to 2008
The next step HPRC takes is to cut the Texas Active Physician file down to just those physicians who are Direct Patient Care (DPC) Physicians. Prior to 2008, this was accomplished by selecting only those records that indicated a Practice Type of “Direct Patient Care” in combination with a Practice Setting of “Hospital Based,” “Solo,” “Partnership/Group,” “Other,” or if the field was left blank. The possible values for those fields were:
1 = Direct Patient Care
2 = Medical Teaching or Medical School Faculty
3 = Administrative Medicine
4 = Research
5 = Not in Practice
6 = Resident, Fellow
0 = Did Not Answer
1 = Military
2 = VA
3 = PHS
4 = HMO
5 = Hospital Based
6 = Solo
7 = Partnership/Group
8 = Other
0 = Did Not Answer
The reasoning behind making these selections is that only Direct Patient Care Physicians (not Faculty, Researchers, etc.) are actually treating patients as opposed to doing administrative work, teaching, or research; and, that Military, VA (Veterans Affairs), and PHS (Public Health Service) Physicians are not accessible to the general public and should not be included in the physician supply ratios. This methodology is also used by the federal Health Resources and Services Administration when determining if an area qualifies as a Medically Underserved Area or a Health Professional Shortage Area. Although Residents and Fellows do provide direct care to patients, it has been a long-standing practice not to include them in the tables of Active Direct Patient Care Physicians.
2008 and later:
In 2008, the Texas Medical Board added new categories, codes 9-12, to the Practice Setting field, as shown below:
1 = Military
2 = VA
3 = PHS
4 = HMO
5 = Hospital Based
6 = Solo
7 = Partnership/Group
8 = Other
9 = Research
10 = Medical School Faculty
11 = Direct Medical Care
12 = Not Applicable
0 = Did Not Answer
This has complicated the selections somewhat, as now both the Practice Setting and Practice Type fields include a category for Direct Patient/Medical Care. Unlike with the previous Practice Setting/Type categories, it is now possible to determine if a physician is involved in both Research and Direct Patient Care. Therefore, beginning with 2008 data and at the recommendation of the Texas Medical Association, HPRC now includes these combinations in the Direct Patient Care file:
Practice Type = Direct Patient Care and
Practice Setting = Did Not Answer, HMO, Hospital Based, Solo, Partnership/Group, Other, Research, Medical School Faculty, Direct Medical Care, Not Applicable, or if the field was left blank;
Practice Setting = Direct Medical Care and
Practice Type = Medical Teaching or Medical School Faculty, Research, or Did Not Answer.
In 2008, 11,744 records did not fall into any of the categories above and were removed.
Also, this change resulted in 22 records that indicated Research in either the Practice Type or Practice Setting field (as long as paired with Direct Patient/Medical Care) and 605 records that indicated Faculty in either the Practice Type of Practice Setting field (as long as paired with Direct Patient/Medical Care) being counted as Direct Patient Care in 2008, when they would not have been counted under the previous methodology, for a approximate total of an additional 627 records above the usual yearly increase.
It must be noted that it is difficult to specify exactly how many records are removed for being “out-of-state,” “Inactive,” or other reasons such as “Military,” because that number can vary depending on the order in which these editing steps are taken, as a record may be removed for more than one reason. For example, a record may be an “out-of-state” record, an “Inactive” record, and a “Military” record. If the “out-of-state” records are removed first, then this record would not be counted in the number of “Inactive” or “Military” records removed.
After making all of the above edits, the resulting file is the "Direct Patient Care Physician" file, and those numbers, by county, are posted on the HPRC website.
Determination of Primary Care Physicians:
The Direct Patient Care file is further edited to prepare the Primary Care Physician file, which includes only those physicians who indicate a Primary Specialty that is one of the Primary Care specialties.
In the past, the specialties that were considered to be Primary Care were Family Practice, General Practice, Obstetrics and/or Gynecology, Pediatrics, and Internal Medicine. Geriatrics was added in 2004 at the request of the Health Resources and Services Administration; there were only 28 of these records in 2004. In 2006, some Family Practice physicians began to identify themselves as Family Medicine physicians, so both categories are included on the Primary Care file. This is not an additional specialty but rather just a change in terminology. In 2008, HPRC began to include those physicians with a specialty of Adolescent Medicine, on the recommendation of the Texas Medical Association, as this specialty is considered a subset of Pediatrics. These records are included with Pediatricians when reporting Primary Care specialty data. In 2008, there were only 8 records indicating Adolescent Medicine. A complete listing of all of the variations of Primary Care specialties is below.
In 2008, 21,859 records were removed from the Direct Patient Care file for having a specialty that was not Primary Care. This resulting file is the "Primary Care Physician" file, which is used to prepare the Primary Care tables on the HPRC website.
Complete listing of Primary Care specialties:
Adolescent Medicine - GP
Adolescent Medicine - IM
Adolescent Medicine - PD
Family Practice - Emergency Medicine
Geriatric Medicine (Family Practice)
Geriatric Medicine (Internal Medicine)
Internal Medicine - Emergency Medicine
Internal Medicine - Pediatrics
Internal Medicine - Psychiatry
Obstetrics and Gynecology
For reporting purposes, the specialties above are usually aggregated into the categories Family Practice, General Practice, Obstetrics and Gynecology, Pediatrics, Internal Medicine, and Geriatrics (based on the first specialty listed for those with a combination of two specialties).
Determination of County:
Since many health professionals practice in a county different from the one in which they live, HPRC prefers to report data by "County of Practice," as this gives a more accurate picture of where health professionals are actually providing care, and which counties may have shortages. However, many licensing boards only report a "Mailing Address." And, for those professions for which both Mailing and Practice addresses are collected, there are usually a substantial number of licensees who do not report their Practice address. In those cases, a health professional's Practice county field is determined by his/her mailing address. This can create a problem when trying to determine the supply and distribution of professionals by county. In addition, addresses are sometimes difficult to geocode with Geographic Information Systems (GIS) programs. For example, sometimes a hospital's name is provided by the licensee as his/her Practice address, rather than the hospital's street address. Post Office Boxes and Route Numbers are also difficult to geocode. And, a number of Practice addresses are often incomplete; for example, the City name may be provided but not a street address or zip code, and, since there are many cities in Texas that are partially located in more than one county, this may yield inaccurate results. For example, a licensee who gives only the City of Dallas as his/her practice address is likely to be coded to Dallas County, when that person may actually be practicing in Denton County or Collin County.
Sometimes, at the request of other organizations HPRC collaborates with, or due to HPRC’s own desire to increase the accuracy of data reporting, changes are made in the methodology in which the files are processed. While this should result in more accurate data, the result is that sometimes the numbers change significantly from one year to the next, falsely implying that there was a large increase or decrease in the number of physicians. HPRC attempts to document these changes when they occur. Below are some of the major changes that have occurred in recent years that may affect the reported numbers of physicians:
- In 2002, HPRC began using GIS software (geocoding) to assign the mailing and practice counties to the Physician files. Prior to that, the county was determined by linking a file obtained from the Post Office of all the zip codes in Texas, and the county in which they were located, with the zip codes on the Physician files. This was not completely accurate, as there are often data entry errors in the zip code field, and, many zip codes cross county lines. Geocoding the files has increased the accuracy of the data.
- In 2004, Geriatrics was added as a Primary Care Specialty (there were 28 of them that year).
- In 2008, several new Practice Setting Codes were added (the Texas Medical Board actually intended these to be added with the 2006 data, but errors in the file layout prevented HPRC from receiving this information). At the recommendation of the Texas Medical Association, it was decided that HPRC will include any record that has Direct Patient Care as the Practice Type (code 1), with the exception of those that have Practice Settings of Military, VA, or PHS (codes 1-3). Also, HPRC will include all records that have a Practice Setting of Direct Medical Care (code 11), unless the Practice Type is Administrative Medicine, Not in Practice or Resident/Fellow (codes 3, 5 & 6).
HPRC considers Psychiatrists to be any Active Direct Patient Care Physician with one of these Primary Specialties:
Child and Adolescent Psychiatry
Prior to 2008, only Psychiatrists and Child Psychiatrists were included.
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