Rural Health Roundtable October 2, 2008 Robert A. Barish, M.D. Vice Dean, Clinical Affairs Professor , Emergency Medicine ...
National Issue <ul><li>The United States will face a serious doctor shortage in the next few decades.  Our nation’s rapidl...
Goals of the Study <ul><li>Document current and future shortages by region and specialty </li></ul><ul><li>Determine impac...
Maryland Physician Workforce Study Steering Committee <ul><li>*Robert A. Barish ,  M.D.,  Chair </li></ul><ul><li>Vice Dea...
Study Approach <ul><li>Quantitative (Data) and Qualitative (Surveys) </li></ul><ul><li>Supply ->Refined Licensure Data </l...
<ul><li>Primary Care </li></ul><ul><li>Family Medicine </li></ul><ul><li>Geriatric Medicine </li></ul><ul><li>Internal Med...
<ul><li>Hospital-Based </li></ul><ul><li>Anesthesiology </li></ul><ul><li>Diagnostic Radiology </li></ul><ul><li>Emergency...
Step 1: Calculation of Baseline Practicing Physician Supply Currently Licensed Physician Supply 24,968 Adjusted Baseline P...
Step 2: Calculation of 2007 Clinical Physician Supply   Adjusted by % Clinical Status Full-Time/Part-Time status and Clini...
Step 4: Forecast Physician Supply    for 2010 & 2015 Clinical  Physician Supply 2007 Retirements/ Deaths Gender/ Lifestyle...
Step 5: Calculate Impact of Residents in Graduate Medical Education Programs <ul><li>Analyze resident data </li></ul><ul><...
Total Clinical Physicians per 100,000 Residents by Region Compared to  State and National Levels US MD
Percentage of Medical Specialists Age 60 and Older by Region 2007 <ul><li>Medical Specialties  significantly impacted  by ...
Overall Observations Regarding Primary Care Requirements versus Supply <ul><li>Quantitative Observations </li></ul><ul><ul...
Medical Specialty Requirements “  Pediatric sub-specialties are hard to find. Half the pediatric population in hospitals a...
Overall Observations Regarding Medical Specialty Requirements versus Supply <ul><li>Quantitative Observations </li></ul><u...
Overall Observations Regarding Surgical Physician Requirements versus Supply <ul><li>Quantitative Observations </li></ul><...
Future vs. Historical Trends <ul><li>Major variables where change may occur: </li></ul><ul><li>In- and Out-Migration of Ph...
Summary of Findings
Maryland Physician Workforce Study – Current Physician Shortages by Region 2007 Legend Adequate Physician Supply Borderlin...
Maryland Physician Workforce Study – Current Physician Shortages by Region 2015 Legend Adequate Physician Supply Borderlin...
Summary of Findings “ We need to develop models that allow doctors to come together to command economic value for their se...
Major Conclusions. . . Maryland has a Growing Physician Crisis   <ul><li>Maryland has 16 percent fewer physicians (clinica...
Major Conclusions. . . <ul><li>Statewide shortages exist in Primary Care, Psychiatry, Hematology/Oncology, Anesthesiology,...
Major Conclusions. . . <ul><ul><li>Critical shortages in primary care physicians and most medical specialties exist today ...
Major Conclusions. . . <ul><li>Hospital-based specialty shortages most acute in Emergency Medicine in the Central, Souther...
Major Conclusions. . . <ul><li>If resident in-training retention rates decrease, forecasted physician supply in 2010 and 2...
Recruitment and Retention:  Reimbursement POLICY RECOMMENDATIONS <ul><li>Governor’s Task Force on Health Care Access and R...
POLICY RECOMMENDATIONS Recruitment and Retention: Medical Liability <ul><li>Make Maryland competitive from a medical liabi...
POLICY RECOMMENDATIONS <ul><li>State :  Loan forgiveness program to attract and retain residents in rural areas with speci...
POLICY RECOMMENDATIONS <ul><li>Residency program directors :  Create forum to increase in-state retention of their trainee...
POLICY RECOMMENDATIONS <ul><li>Increase the number of residency slots. </li></ul>Retention of Maryland Residents  (Cont’d.)
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Rural Health Roundtable

  1. 1. Rural Health Roundtable October 2, 2008 Robert A. Barish, M.D. Vice Dean, Clinical Affairs Professor , Emergency Medicine and Medicine University of Maryland School of Medicine Maryland Physician Workforce Study
  2. 2. National Issue <ul><li>The United States will face a serious doctor shortage in the next few decades. Our nation’s rapidly growing population, increasing numbers of elderly Americans, and aging physician workforce, and a rising demand for health care services all point to this conclusion. </li></ul><ul><li>Source: AAMC </li></ul>
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  11. 11. Goals of the Study <ul><li>Document current and future shortages by region and specialty </li></ul><ul><li>Determine impact on access </li></ul><ul><li>Document key physician environment issues and potential impact on supply </li></ul><ul><li>Engage physicians and hospitals in the discussion and develop consensus for solutions </li></ul>
  12. 12. Maryland Physician Workforce Study Steering Committee <ul><li>*Robert A. Barish , M.D., Chair </li></ul><ul><li>Vice Dean for Clinical Affairs, University of Maryland School of Medicine </li></ul><ul><li>*John Colmers , Secretary, </li></ul><ul><li>Dept. of Health & Mental Hygiene </li></ul><ul><li>*Rex W. Cowdry, M.D., Exec. Dir., Maryland Health Care Comm. </li></ul><ul><li>Blair Eig, M.D., VP Medical Affairs, Holy Cross Hospital </li></ul><ul><li>Richard Grossi , CFO </li></ul><ul><li>Johns Hopkins Medicine </li></ul><ul><li>Scott Hagaman, M.D. </li></ul><ul><li>President, MedChi </li></ul><ul><li>*Harry C. Knipp, M.D., Chair </li></ul><ul><li>Maryland Board of Physicians </li></ul><ul><li>Scott E. Maizel, M.D. </li></ul><ul><li>Surgery Representative </li></ul><ul><li>Stephen J. Rockower, M.D. </li></ul><ul><li>Medical Specialty Representative </li></ul><ul><li>Joseph Twanmoh, M.D., FACEP </li></ul><ul><li>Vice President, American College of </li></ul><ul><li>Emergency Physicians, MD Chapter </li></ul><ul><li>Joseph W. Zebley, III, M.D., FAAFP </li></ul><ul><li>Primary Care Representative </li></ul>*State agency representatives participated on the Steering Committee to assist the effort without taking a position on its policy recommendations.
  13. 13. Study Approach <ul><li>Quantitative (Data) and Qualitative (Surveys) </li></ul><ul><li>Supply ->Refined Licensure Data </li></ul><ul><li>Requirements->Population-Based Demand Benchmarks </li></ul><ul><li>Study Period: 2007 - 2015 </li></ul><ul><li>Analysis of Variation by Specialty Group </li></ul><ul><li>Analysis for Five Maryland Health Planning Regions </li></ul>
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  15. 15. <ul><li>Primary Care </li></ul><ul><li>Family Medicine </li></ul><ul><li>Geriatric Medicine </li></ul><ul><li>Internal Medicine </li></ul><ul><li>Pediatrics </li></ul><ul><li>Medical Specialty </li></ul><ul><li>Allergy </li></ul><ul><li>Cardiology </li></ul><ul><li>Dermatology </li></ul><ul><li>Endocrinology </li></ul><ul><li>Gastroenterology </li></ul><ul><li>Hematology/Oncology </li></ul><ul><li>Infectious Disease </li></ul><ul><li>Nephrology </li></ul><ul><li>Neurology </li></ul><ul><li>Psychiatry </li></ul><ul><li>Pulmonary Medicine </li></ul><ul><li>Rheumatology </li></ul>
  16. 16. <ul><li>Hospital-Based </li></ul><ul><li>Anesthesiology </li></ul><ul><li>Diagnostic Radiology </li></ul><ul><li>Emergency Medicine </li></ul><ul><li>Neonatology </li></ul><ul><li>Pathology </li></ul><ul><li>Physical Medicine </li></ul><ul><li>Radiation Oncology </li></ul><ul><li>Surgical Specialty </li></ul><ul><li>General Surgery </li></ul><ul><li>Neurosurgery </li></ul><ul><li>OB/GYN </li></ul><ul><li>Ophthalmology </li></ul><ul><li>Orthopedic Surgery </li></ul><ul><li>Otolaryngology </li></ul><ul><li>Plastic Surgery </li></ul><ul><li>Thoracic Surgery </li></ul><ul><li>Urology </li></ul><ul><li>Vascular Surgery </li></ul>
  17. 17. Step 1: Calculation of Baseline Practicing Physician Supply Currently Licensed Physician Supply 24,968 Adjusted Baseline Physician Supply 14,891 MINUS EQUALS Source: Maryland Board of Physicians Federally Employed Except VA 1,485 Practice Site Out-of-State 4,212 Non-practicing physicians 2,664 Non-renewals 1,716
  18. 18. Step 2: Calculation of 2007 Clinical Physician Supply Adjusted by % Clinical Status Full-Time/Part-Time status and Clinical Status are based on edits of the Board of Physician data by the Medical Directors at Maryland hospitals. Adjusted Baseline Physician Supply 14,891 Adjusted by FT/PT Status Total Clinical Physician Supply 10,227
  19. 19. Step 4: Forecast Physician Supply for 2010 & 2015 Clinical Physician Supply 2007 Retirements/ Deaths Gender/ Lifestyle Net In-Migration Residents Remaining In MD Forecasted Clinical Physician Supply 2010 & 2015 MINUS EQUALS PLUS
  20. 20. Step 5: Calculate Impact of Residents in Graduate Medical Education Programs <ul><li>Analyze resident data </li></ul><ul><li>Adjust for work effort based on recommendations by residency program directors: </li></ul><ul><ul><li>Primary Care: 0.3 FTE </li></ul></ul><ul><ul><li>Medical Specialties: 0.3 FTE </li></ul></ul><ul><ul><li>Hospital Based Specialties: 0.15 FTE </li></ul></ul><ul><ul><li>Surgical Specialties: 0.15 FTE </li></ul></ul>
  21. 21. Total Clinical Physicians per 100,000 Residents by Region Compared to State and National Levels US MD
  22. 22. Percentage of Medical Specialists Age 60 and Older by Region 2007 <ul><li>Medical Specialties significantly impacted by retirements (age of the workforce) </li></ul><ul><li>Capital and Eastern regions have highest percentage of physicians over Age 60 </li></ul>
  23. 23. Overall Observations Regarding Primary Care Requirements versus Supply <ul><li>Quantitative Observations </li></ul><ul><ul><li>Greatest shortages in 3 rural regions </li></ul></ul><ul><ul><li>Southern Maryland has shortages under all 3 scenarios and decreasing resources from 2007-2015 </li></ul></ul><ul><ul><li>Maryland becoming more dependent on allied health professionals to supplement primary care physicians </li></ul></ul><ul><li>Qualitative Observations by Medical Directors </li></ul><ul><ul><li>Primary care cited as greatest physician recruitment need by 43% of Medical Directors </li></ul></ul><ul><ul><li>Out-of-state recruitment increasingly difficult- (Maryland not competitive from a compensation & cost-of-living standpoint) </li></ul></ul><ul><ul><li>Recent graduates not selecting community-based practice </li></ul></ul>
  24. 24. Medical Specialty Requirements “ Pediatric sub-specialties are hard to find. Half the pediatric population in hospitals are on medical assistance or uninsured. If I see a complex MA patient in the clinic I get paid $15. If the hospital nutritionist sees the patient the hospital receives $80. Medical Director-Pediatric Program
  25. 25. Overall Observations Regarding Medical Specialty Requirements versus Supply <ul><li>Quantitative Observations </li></ul><ul><ul><li>Medical specialty shortages in 3 rural regions </li></ul></ul><ul><ul><li>Principal statewide shortages: Dermatology, Gastroenterology, Hem/Onc & Psychiatry </li></ul></ul><ul><ul><li>Medical specialists predicted to decrease per 100,000 residents statewide from 39.9 in 2007 to 37.3 in 2015 — greatest decrease in Capital Region (i.e. from 44.2 to 37.3) </li></ul></ul><ul><li>Qualitative Observations by Medical Directors </li></ul><ul><ul><li>Greatest need: Gastroenterology cited by 17% of medical directors </li></ul></ul><ul><ul><li>Major concerns cited: Call coverage of ED & ability to replace retiring physicians </li></ul></ul>
  26. 26. Overall Observations Regarding Surgical Physician Requirements versus Supply <ul><li>Quantitative Observations </li></ul><ul><ul><li>General Surgery: Specialty with greatest need </li></ul></ul><ul><ul><li>Downward Supply Trends 2007-2015: Forecasted in-migration and new residents insufficient to cover retirements in many surgical specialties </li></ul></ul><ul><ul><li>Thoracic Surgery: Greatest impact from retirements </li></ul></ul><ul><li>Qualitative Observations by Hospital Medical Directors </li></ul><ul><ul><li>Recruitment Priorities: (% of medical directors citing surgical needs): General Surgery (38%), Orthopedic Surgery (30%), OB/GYN (28%), ENT (23%), Neurosurgery (17%) & Vascular Surgery (17%) </li></ul></ul><ul><ul><li>Hospital Recruitment Strategy: Pursuing employed model to address both competitive compensation & on call needs </li></ul></ul>
  27. 27. Future vs. Historical Trends <ul><li>Major variables where change may occur: </li></ul><ul><li>In- and Out-Migration of Physicians </li></ul><ul><li>Percent of medical residents staying to practice in Maryland </li></ul><ul><li>Physician retirement trends, especially in high stress specialties </li></ul><ul><li>Physician productivity </li></ul><ul><li>Economic growth in Maryland. </li></ul><ul><li>Need to update physician workforce analysis every few years. </li></ul>
  28. 28. Summary of Findings
  29. 29. Maryland Physician Workforce Study – Current Physician Shortages by Region 2007 Legend Adequate Physician Supply Borderline Physician Supply Physician Shortage *Physician Only **Physician & Resident Model Capital Central Eastern Southern Western Primary Care *: Primary Care MDs Medical Specialty : Allergy Cardiology Dermatology Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Nephrology Neurology Psychiatry Pulmonary Medicine Rheumatology Hospital-Based : Anesthesiology** Diagnostic Radiology Emergency Medicine Neonatology Pathology Physical Medicine Radiation Oncology Surgical Specialty : General Neurosurgery Obstetrics/Gynecology Ophthalmology Orthopedic Otolaryngology Plastic Thoracic Urology Vascular Total 8 5 18 25 20 % of Shortages 27.6% 17.2% 62.1% 86.2% 69%
  30. 30. Maryland Physician Workforce Study – Current Physician Shortages by Region 2015 Legend Adequate Physician Supply Borderline Physician Supply Physician Shortage *Physician Only **Physician & Resident Model Capital Central Eastern Southern Western Primary Care *: Primary Care MDs Medical Specialty : Allergy Cardiology Dermatology Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Nephrology Neurology Psychiatry Pulmonary Medicine Rheumatology Hospital-Based : Anesthesiology** Diagnostic Radiology Emergency Medicine Neonatology Pathology Physical Medicine Radiation Oncology Surgical Specialty : General Neurosurgery Obstetrics/Gynecology Ophthalmology Orthopedic Surg Otolaryngology Plastic Thoracic Urology Vascular Total 11 4 17 27 27 % of Shortages 37.9% 13.8% 58.6% 93.1% 75.9%
  31. 31. Summary of Findings “ We need to develop models that allow doctors to come together to command economic value for their services, but allow them to maintain their autonomy.” Medical Director-Community Hospital
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  33. 33. Major Conclusions. . . Maryland has a Growing Physician Crisis <ul><li>Maryland has 16 percent fewer physicians (clinical full-time equivalent) per population than the U.S. </li></ul><ul><li>Physician shortages are acute in most specialties in the state’s three rural regions. </li></ul>
  34. 34. Major Conclusions. . . <ul><li>Statewide shortages exist in Primary Care, Psychiatry, Hematology/Oncology, Anesthesiology, Emergency Medicine, Pathology, General Surgery, Thoracic Surgery, and Vascular Surgery. Maryland has only a borderline supply of needed Orthopedic Surgeons. </li></ul>
  35. 35. Major Conclusions. . . <ul><ul><li>Critical shortages in primary care physicians and most medical specialties exist today and into 2015 in Southern Maryland, Eastern Shore, and Western Maryland. </li></ul></ul><ul><ul><li>Surgical specialties; e.g., general surgery and thoracic surgery, experiencing critical shortages. </li></ul></ul>
  36. 36. Major Conclusions. . . <ul><li>Hospital-based specialty shortages most acute in Emergency Medicine in the Central, Southern, and Western Maryland regions, and in Anesthesiology & Diagnostic Radiology in all regions except Central. </li></ul><ul><li>Physician workforce will experience significant retirements between 2007 and 2015; especially in medical/surgical specialties and in the Capital area. </li></ul><ul><li>Maryland historically retains 52% of its medical residents, but adverse payment, medical liability, and other environmental factors may reduce retention significantly, leading to greater physician shortages. </li></ul>
  37. 37. Major Conclusions. . . <ul><li>If resident in-training retention rates decrease, forecasted physician supply in 2010 and 2015 will be dramatically less . . . resulting in greater physician shortages. </li></ul><ul><li>In many specialties, physician in-migration plus new medical residents remaining in Maryland will not offset retirements. </li></ul><ul><li>National and international markets for physicians is now extremely competitive. Maryland needs to act to remain competitive. </li></ul>
  38. 38. Recruitment and Retention: Reimbursement POLICY RECOMMENDATIONS <ul><li>Governor’s Task Force on Health Care Access and Reimbursement: Adopt recommendations to make physician reimbursement rates in Maryland nationally competitive. </li></ul><ul><li>Enact legislation to permit physicians to form practice associations to enhance physician recruitment efforts, improve practice efficiency, and negotiate competitive fees. </li></ul><ul><li>Enact legislation to require insurers to pay newly credentialed physicians retroactive to the date they applied to the payor for credentialing. </li></ul><ul><li>Establish enhanced Medicaid reimbursement in shortage areas similar to Medicare. </li></ul>
  39. 39. POLICY RECOMMENDATIONS Recruitment and Retention: Medical Liability <ul><li>Make Maryland competitive from a medical liability perspective with those states that are currently attracting physicians. Examples include: </li></ul><ul><ul><li>Caps on non-economic damage awards equal to Texas’s $250,000 </li></ul></ul><ul><ul><li>Alternative dispute resolution mechanisms </li></ul></ul>
  40. 40. POLICY RECOMMENDATIONS <ul><li>State : Loan forgiveness program to attract and retain residents in rural areas with specialty shortages. </li></ul><ul><li>Hospitals : Loan forgiveness for residents who practice in their areas. </li></ul><ul><li>Maryland teaching programs : Rotations in regions/hospitals with shortages. </li></ul><ul><li>Gain federal support for increased access to National Health Service Corp (NHSC) physicians. </li></ul>Retention of Maryland Residents in Training
  41. 41. POLICY RECOMMENDATIONS <ul><li>Residency program directors : Create forum to increase in-state retention of their trainees. </li></ul><ul><li>Develop regional capitation of some medical school slots. </li></ul><ul><li>GME programs : Partner with hospitals in the three rural regions to identify potential residents for positions in those areas. </li></ul>Retention of Maryland Residents (Cont’d.)
  42. 42. POLICY RECOMMENDATIONS <ul><li>Increase the number of residency slots. </li></ul>Retention of Maryland Residents (Cont’d.)
  43. 43. Comments/Questions
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