Kamemoto lori, sood sneha

390 views

Published on

Kamemoto lori, sood sneha 2008 Perinatal

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
390
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
1
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Kamemoto lori, sood sneha

  1. 1. Access to Health Care in Hawaii:Access to Health Care in Hawaii: the Pediatric and Obstetricsthe Pediatric and Obstetrics Workforce ShortageWorkforce Shortage LoriLori KamemotoKamemoto, MD, MPH, FACOG, MD, MPH, FACOG SnehaSneha Sood, MD, Neonatology; JABSOMSood, MD, Neonatology; JABSOM 2008 Perinatal Health Summit2008 Perinatal Health Summit Waikoloa, HawaiiWaikoloa, Hawaii October 24, 2008October 24, 2008
  2. 2. Workforce Shortage in HawaiiWorkforce Shortage in Hawaii •• Background and National DataBackground and National Data •• Hawaii’s Pediatric WorkforceHawaii’s Pediatric Workforce •• Hawaii’s Obstetrics and GynecologyHawaii’s Obstetrics and Gynecology WorkforceWorkforce •• Solutions?Solutions?
  3. 3. ObjectivesObjectives •• Overview of the healthcare workforceOverview of the healthcare workforce shortage in U.S. and Hawaiishortage in U.S. and Hawaii •• Discuss challenges in access to healthDiscuss challenges in access to health care in Obstetrics and Pediatrics on thecare in Obstetrics and Pediatrics on the neighbor islandsneighbor islands •• Discuss possible solutionsDiscuss possible solutions
  4. 4. Health Care DisparitiesHealth Care Disparities •• HRSA:HRSA: "population"population--specific differences in thespecific differences in the presence of disease, health outcomes, orpresence of disease, health outcomes, or access to health careaccess to health care““ −− Gaps in the quality of healthcare across racial, ethnic,Gaps in the quality of healthcare across racial, ethnic, gender, socioeconomic and other groupsgender, socioeconomic and other groups •• Healthcare disparities wellHealthcare disparities well--documented in U.S.documented in U.S. racial minority groupsracial minority groups −− African Americans, Native Americans and NativeAfrican Americans, Native Americans and Native Hawaiians, Hispanics at higher risk than whites forHawaiians, Hispanics at higher risk than whites for chronic diseases and cancer, higher mortality, andchronic diseases and cancer, higher mortality, and poorer health outcomespoorer health outcomes −− Minorities also have higher infant mortality,Minorities also have higher infant mortality, cardiovascular disease and HIV than whitescardiovascular disease and HIV than whites
  5. 5. Causes of Healthcare DisparitiesCauses of Healthcare Disparities •• EnvironmentEnvironment −− Minorities, on average, live in socioeconomicallyMinorities, on average, live in socioeconomically disadvantaged areasdisadvantaged areas •• Example: children’s lead paint exposureExample: children’s lead paint exposure •• Barriers to Access to careBarriers to Access to care −− Minority groups may have more difficulty accessingMinority groups may have more difficulty accessing healthcarehealthcare •• Examples: insurance issues, rural areas where there are lessExamples: insurance issues, rural areas where there are less physicians, etc.physicians, etc. •• Differences in Quality of careDifferences in Quality of care −− Minority groups may be receiving care, however receiveMinority groups may be receiving care, however receive poorer quality of care resulting in different outcomespoorer quality of care resulting in different outcomes •• Example: African Americans with breast cancer have a higherExample: African Americans with breast cancer have a higher mortalitymortality
  6. 6. Access to HealthcareAccess to Healthcare BarriersBarriers •• No health insurance or insurance that limitsNo health insurance or insurance that limits healthcare services coveredhealthcare services covered •• No Primary Care Provider, no medical homeNo Primary Care Provider, no medical home •• No money/financial meansNo money/financial means •• Legal barriers: immigrantsLegal barriers: immigrants •• Structural barriers: transportation, inconvenientStructural barriers: transportation, inconvenient office hours, excessive time in waiting roomoffice hours, excessive time in waiting room •• Language barrier/Health literacyLanguage barrier/Health literacy •• Lack of diversity in the healthcare workforceLack of diversity in the healthcare workforce •• Scarcity of Health Care ProvidersScarcity of Health Care Providers
  7. 7. Help Wanted: More U.S. Doctors Projections Indicate America Will Face Shortage of M.D.s by 2020 Tomorrow’s Doctors, Tomorrow’s Cures®
  8. 8. Tomorrow’s Doctors, Tomorrow’s Cures® 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, an aging physician workforce, and a rising demand for health care services all point to this conclusion.
  9. 9. AAMC ReportAAMC Report •• Many areas of the country and some healthcareMany areas of the country and some healthcare specialties already reporting a scarcity ofspecialties already reporting a scarcity of physiciansphysicians •• Acute national shortage would have a profoundAcute national shortage would have a profound effect on healthcare:effect on healthcare: −− Longer wait timesLonger wait times −− Longer travel times for careLonger travel times for care −− Elderly, poor, rural residents, and the 20% who areElderly, poor, rural residents, and the 20% who are already medically underserved would be most affectedalready medically underserved would be most affected •• Depending on the specialty, it can take up to 14Depending on the specialty, it can take up to 14 years from the time education is begun to theyears from the time education is begun to the time physician starts practicetime physician starts practice
  10. 10. Number of Elderly will double by 2030Number of Elderly will double by 2030
  11. 11. Doctor Visits sharply higher for over 65Doctor Visits sharply higher for over 65
  12. 12. U.S. has Low Physician toU.S. has Low Physician to Population ratioPopulation ratio
  13. 13. First Year MD Enrollment per 100,000First Year MD Enrollment per 100,000 population declining since 1980population declining since 1980
  14. 14. U.S. MDs TwoU.S. MDs Two--thirds of thosethirds of those Entering Residency Training, 2005Entering Residency Training, 2005
  15. 15. Physician Workforce is AgingPhysician Workforce is Aging 250,000 Active MDs are over 55250,000 Active MDs are over 55
  16. 16. 30 million Already Live in Federally30 million Already Live in Federally designated Shortage Areasdesignated Shortage Areas
  17. 17. HRSA: 10HRSA: 10--20% Physician20% Physician Shortage by 2020Shortage by 2020 Increase Supply Increase Demand Primary Care 18% 20-30% Cardiology 8% 33-59% Other IM 12% 27-49% General Surgery -3% 25-45% OB-GYN 14% 10-19% Orthopedics 2% 23-54% Anesthesiology 20% 25-48% Psychiatry 9% 16-46%
  18. 18. Hawaii Population 2006Hawaii Population 2006 1,285,4981,285,498Hawaii StateHawaii State 63,00463,004KauaiKauai 141,320141,320MauiMaui 171,191171,191Island of HawaiiIsland of Hawaii 909,863909,863OahuOahu U.S. Census Bureau Quick Facts
  19. 19. Island of Hawaii Population, 2005Island of Hawaii Population, 2005 County of HawaiiCounty of Hawaii DatabookDatabook, 2006, 2006 6,4436,443KauKau 40,72040,720North and South KonaNorth and South Kona 22,28122,281North and SouthNorth and South KohalaKohala 90,46390,463 Hilo (North and South),Hilo (North and South), HamakuaHamakua,, PunaPuna
  20. 20. Hawaii HospitalsHawaii Hospitals Hawaii County HospitalsHawaii County Hospitals •• Hilo Medical Center (HHSC)*Hilo Medical Center (HHSC)* •• North Hawaii Hospital (private)*North Hawaii Hospital (private)* •• Kona Medical Center (HHSC)*Kona Medical Center (HHSC)* •• KauKau Hospital (HHSC)Hospital (HHSC) •• HaleHale KoKo’’olaola HamakuaHamakua (HHSC)(HHSC) –– formerly Honokaa Hospitalformerly Honokaa Hospital –– long term care facilitylong term care facility •• KohalaKohala Hospital (HHSC)Hospital (HHSC) –– Long termLong term –– AcuteAcute Kauai HospitalsKauai Hospitals •• Wilcox Hospital (HPH)*Wilcox Hospital (HPH)* •• West Kauai Medical Center (HHSC,West Kauai Medical Center (HHSC, Kauai Veterans Hospital)*Kauai Veterans Hospital)* •• SamuelSamuel MahelonaMahelona Hospital (HHSC)Hospital (HHSC) −− acute careacute care Maui County HospitalsMaui County Hospitals •• MauiMaui –– Maui Memorial HospitalMaui Memorial Hospital (HHSC)*(HHSC)* –– Kula Hospital (HHSC)Kula Hospital (HHSC) •• Mostly long term careMostly long term care •• LanaiLanai –– Lanai Community HospitalLanai Community Hospital (HHSC)(HHSC) •• Limited acute careLimited acute care •• Long term careLong term care •• No deliveriesNo deliveries •• MolokaiMolokai –– Molokai Community HospitalMolokai Community Hospital (Queen’s Healthcare System)*(Queen’s Healthcare System)* * Provides mother/baby care
  21. 21. Critical Access Hospitals (CAH)*Critical Access Hospitals (CAH)* •• “To assist small rural hospitals and improve access to health se“To assist small rural hospitals and improve access to health servicesrvices in rural communities”, established 1997in rural communities”, established 1997 –– More than 35 road miles or, in mountainous terrain or where onlyMore than 35 road miles or, in mountainous terrain or where only secondary roads exist, more than 15 road miles from another hospsecondary roads exist, more than 15 road miles from another hospitalital –– Provide 24Provide 24--hour emergency care that is necessary for ensuring access tohour emergency care that is necessary for ensuring access to emergency care services in the area served by the facilityemergency care services in the area served by the facility –– No more than 25 acute care inpatient bedsNo more than 25 acute care inpatient beds –– Provide average inpatient care for a period not exceeding 96 houProvide average inpatient care for a period not exceeding 96 hoursrs •• CAH in Hawaii:CAH in Hawaii: –– HaleHale HoolaHoola HamakuaHamakua –– KahukuKahuku HospitalHospital –– KauKau HospitalHospital –– Kauai Veterans Memorial HospitalKauai Veterans Memorial Hospital –– KohalaKohala HospitalHospital –– Lanai Community HospitalLanai Community Hospital –– Molokai General HospitalMolokai General Hospital –– SamuelSamuel MahelonaMahelona Memorial HospitalMemorial Hospital
  22. 22. Health Professional Shortage AreaHealth Professional Shortage Area •• An urban or rural area, which need not conform to geographicAn urban or rural area, which need not conform to geographic boundaries of a political subdivision, and is a rational area foboundaries of a political subdivision, and is a rational area for ther the delivery of health servicesdelivery of health services •• Primary Care Physician: General or Family Practice, general IntPrimary Care Physician: General or Family Practice, general Internalernal Medicine, general Pediatrics and Obstetrics/Gynecology with anMedicine, general Pediatrics and Obstetrics/Gynecology with an active practice in the communityactive practice in the community •• DHHS recommends one primary care physician per 2,000 people inDHHS recommends one primary care physician per 2,000 people in adequately served areas*adequately served areas* •• Health Professional Shortage Areas defined as one primary careHealth Professional Shortage Areas defined as one primary care physician per 3,500 or more people.*physician per 3,500 or more people.* •• Shortage of specialty care physicians (e.g.Shortage of specialty care physicians (e.g.--cardiology, orthopediccardiology, orthopedic surgery and others) also greatly affect the population’s health.surgery and others) also greatly affect the population’s health.
  23. 23. Primary Care PractitionersPrimary Care Practitioners DHHSDHHS •• All nonAll non--Federal doctors of medicine (M.D.)Federal doctors of medicine (M.D.) and doctors of osteopathy (D.O.) providingand doctors of osteopathy (D.O.) providing direct patient care who practice principally indirect patient care who practice principally in one of the four primary care specialtiesone of the four primary care specialties −− General or Family Practice, General InternalGeneral or Family Practice, General Internal Medicine, Pediatrics, and Obstetrics andMedicine, Pediatrics, and Obstetrics and GynecologyGynecology •• Physicians engaged solely in administration,Physicians engaged solely in administration, research, and teaching are excluded forresearch, and teaching are excluded for counting purposescounting purposes
  24. 24. Primary Care ProvidersPrimary Care Providers Health Professional Shortage AreasHealth Professional Shortage Areas •• Department of Health and Human ServicesDepartment of Health and Human Services (DHHS)(DHHS) •• Recommends one primary care physician (PCP)Recommends one primary care physician (PCP) per 2000 people in adequately served areasper 2000 people in adequately served areas •• Health Professional Shortage Areas (HPSA)Health Professional Shortage Areas (HPSA) defined as one primary care physician per 3500defined as one primary care physician per 3500 people or morepeople or more
  25. 25. Determination of Unusually High Needs forDetermination of Unusually High Needs for Primary Medical Care ServicesPrimary Medical Care Services -- DHHSDHHS An area will be considered as having UnusuallyAn area will be considered as having Unusually High Needs for Primary Health Care Services ifHigh Needs for Primary Health Care Services if at least one of the following criteria is met:at least one of the following criteria is met: (a) The area has more than 100 births per year per(a) The area has more than 100 births per year per 1,000 women aged 151,000 women aged 15 -- 4444 (b) More than 20 infant deaths per 1,000 live births(b) More than 20 infant deaths per 1,000 live births (c) More than 20% of the population (or of all(c) More than 20% of the population (or of all households) have incomes below the poverty levelhouseholds) have incomes below the poverty level
  26. 26. Health Professional Shortage AreasHealth Professional Shortage Areas Hawaii Health Information Corporation Website
  27. 27. Determination of Insufficient Capacity ofDetermination of Insufficient Capacity of Existing Primary Care ProvidersExisting Primary Care Providers -- DHHSDHHS An area's existing primary care providers will be consideredAn area's existing primary care providers will be considered to have Insufficient Capacity if at least two of the followingto have Insufficient Capacity if at least two of the following criteria are met:criteria are met: (a) More than 8,000 office or outpatient visits per year per FTE(a) More than 8,000 office or outpatient visits per year per FTE PCPPCP (b) Unusually long waits for appointments for routine medical se(b) Unusually long waits for appointments for routine medical servicesrvices (i.e., more than 7 days for established patients and 14 days for(i.e., more than 7 days for established patients and 14 days for newnew patients)patients) (c) Excessive average waiting time at primary care providers (lo(c) Excessive average waiting time at primary care providers (longernger than one hour where patients have appointments or two hours wherthan one hour where patients have appointments or two hours wheree patients are treated on a firstpatients are treated on a first--come, firstcome, first--served basis)served basis) (d) Evidence of excessive use of emergency room facilities for r(d) Evidence of excessive use of emergency room facilities for routineoutine primary careprimary care (e) A substantial proportion (2/3 or more) of the area's physici(e) A substantial proportion (2/3 or more) of the area's physicians doans do not accept new patientsnot accept new patients (f) Abnormally low utilization of health services, as indicated(f) Abnormally low utilization of health services, as indicated by anby an average of 2.0 or less office visits per year on the part of theaverage of 2.0 or less office visits per year on the part of the area'sarea's populationpopulation
  28. 28. Challenges faced byChallenges faced by Rural PhysiciansRural Physicians •• Longer Work HoursLonger Work Hours −− More patientsMore patients −− More complicated patient careMore complicated patient care −− Harder to refer patients for specialist careHarder to refer patients for specialist care--lack of specialtylack of specialty carecare −− Physicians not only face an increased outpatient load, but arePhysicians not only face an increased outpatient load, but are also responsible for providing increased inalso responsible for providing increased in--hospital serviceshospital services during the day, night and weekendsduring the day, night and weekends •• More patient visitsMore patient visits −− Example: Hilo Ob sees about 60Example: Hilo Ob sees about 60--100 patients per day in the100 patients per day in the office; busy Honolulu Ob sees up to 40 patients per dayoffice; busy Honolulu Ob sees up to 40 patients per day •• Less favorable insurance distributionLess favorable insurance distribution −− More Medicaid/QUEST patientsMore Medicaid/QUEST patients −− More patients with no insuranceMore patients with no insurance •• Resulting in lower income per patientResulting in lower income per patient
  29. 29. American Medical Association. Socioeconomic Characteristics of Medical Practice 1996. Chicago, IL: American Medical Association, 1996. Physician Hours Worked Per WeekPhysician Hours Worked Per Week
  30. 30. Total Number of Patients Per WeekTotal Number of Patients Per Week American Medical Association. Socioeconomic Characteristics of Medical Practice 1996. Chicago, IL: American Medical Association, 1996.
  31. 31. Percentage of Physician RevenuePercentage of Physician Revenue from Medicare and Medicaidfrom Medicare and Medicaid Frenzen Paul D. The Medicare and Medicaid Programs in Rural America. U.S. Department of Agriculture, March 1996.
  32. 32. Physician Average Gross PracticePhysician Average Gross Practice Revenues/IncomeRevenues/Income American Medical Association. Socioeconomic Characteristics of Medical Practice 1996. Chicago, IL: American Medical Association, 1996.
  33. 33. Health Disparities on the Neighbor IslandsHealth Disparities on the Neighbor Islands •• Lack of health care providersLack of health care providers –– Physician ShortagePhysician Shortage –– Lack of Subspecialists and Subspecialty ClinicsLack of Subspecialists and Subspecialty Clinics –– Nursing shortageNursing shortage •• SocioeconomicSocioeconomic –– IncomeIncome –– Drug useDrug use –– Health insuranceHealth insurance •• GeographyGeography –– Sparse populationSparse population –– Lack of transportationLack of transportation •• Race/Ethnic: cultural factorsRace/Ethnic: cultural factors
  34. 34. Hawaii Population by Ethnicity (%)Hawaii Population by Ethnicity (%) 20062006 0% 20% 40% 60% 80% 100% State Hawaii County Two or more Hispanic or Latino Asian Hawaiian/Pacific Isl Am Indian/Alaska Nat Caucasian Af AmericanState U.S. Census Bureau Quick Facts 2006 State Haw aii Co Af Am eric 2.5 0.7 Caucasian 28.6 37 Am Indian 0.5 0.7 Haw aiian/ 9.1 10.8 Asian 40 24.3 Hispanic o 7.8 10.8 Tw o or mo 19.4 26.5
  35. 35. Median Household Income, 2004Median Household Income, 2004 $44,334$44,334U.S.A.U.S.A. $45,146$45,146KauaiKauai $49,065$49,065MauiMaui $42,043$42,043Island of HawaiiIsland of Hawaii $54,714$54,714OahuOahu $51,359$51,359Hawaii StateHawaii State U.S. Census Bureau Quick Facts
  36. 36. Persons Below Poverty Level, 2004Persons Below Poverty Level, 2004 12.7%12.7%U.S.A.U.S.A. 8.6%8.6%KauaiKauai 8.3%8.3%MauiMaui 10.8%10.8%Island of HawaiiIsland of Hawaii 8.8%8.8%OahuOahu 9.0%9.0%Hawaii StateHawaii State U.S. Census Bureau Quick Facts
  37. 37. Hawaii InsuranceHawaii Insurance PayorPayor MixMix Hawaii Health Information Corporation, Non-federal hospitals only
  38. 38. Hawaii Health Information Corporation, Inpatient Database, Non-federal hospitals only. Hawaii’s Uninsured Population, 2003-2005
  39. 39. Hawaii PhysiciansHawaii Physicians •• Physicians per population: State of Hawaii ranksPhysicians per population: State of Hawaii ranks 77thth in the U.S. with 3,770 physicians (2007 AAMCin the U.S. with 3,770 physicians (2007 AAMC Physician WorkforcePhysician Workforce DatabookDatabook)) −− 293.3 active physicians per 100,000 population293.3 active physicians per 100,000 population •• 47% of Hawaii MDs are over 50 years old (AMA)47% of Hawaii MDs are over 50 years old (AMA) −− Hawaii ranks 7Hawaii ranks 7thth for number of physicians over 60 yearsfor number of physicians over 60 years of age (25% > 60 years) (2007 State Workforceof age (25% > 60 years) (2007 State Workforce Handbook)Handbook) −− Who will replace them as they retire?Who will replace them as they retire? •• Patients still unable to find primary care providersPatients still unable to find primary care providers and certain areas of specialty care, particularly onand certain areas of specialty care, particularly on the neighbor islandsthe neighbor islands
  40. 40. Inadequate DistributionInadequate Distribution of Hawaii Physiciansof Hawaii Physicians •• May be adequate number of health care providersMay be adequate number of health care providers in Hawaii, however, disproportionate distribution ofin Hawaii, however, disproportionate distribution of providers resulting in inadequate supply in ruralproviders resulting in inadequate supply in rural areasareas •• ~~ 79% of Hawaii physicians on Oahu79% of Hawaii physicians on Oahu –– 4% Kauai4% Kauai –– 8% Maui8% Maui –– 9% Island of Hawaii9% Island of Hawaii •• Growing neighbor island population, but physicianGrowing neighbor island population, but physician numbers not increasingnumbers not increasing Inada,Withy,Andaya,HixonInada,Withy,Andaya,Hixon, 2005, 2005
  41. 41. Lack of Access to Health Care:Lack of Access to Health Care: Geographical LocationGeographical Location
  42. 42. Ob/Gyn Residency ProgramOb/Gyn Residency Program Applications DecliningApplications Declining PGY 1 2002 2003 2004 Number of Positions offered 1130 1151 1142 Number of US Seniors Applying 920 828 743 Number of total Applicants 1389 1367 1118 Positions Per US Senior 1.2 1.4 1.5 Positions Per Total Applicants 0.8 0.8 1.02 Number of Positions Filled by US Seniors (%) 850 (75.2) 786 (68.3) 743 (65.1) Number of Positions Filled, Total Applicants (%) 1067 (94.4) 1050 (91.2) 1066 (95.3) Number of Unfilled Positions (%) 63 (5.5) 101 (8.8) 76 (6.7) National Residency Matching Program data
  43. 43. Obstetrics and Gynecology PracticeObstetrics and Gynecology Practice •• In a typical week there are approximately 85In a typical week there are approximately 85 patient contacts (80% seen in the office andpatient contacts (80% seen in the office and 20% in the hospital/surgery), ACOG20% in the hospital/surgery), ACOG •• Women of a wide age range, nearly 80% areWomen of a wide age range, nearly 80% are 1515––45 years old45 years old −− ~~ 70% of patients cared for by an obstetrician70% of patients cared for by an obstetrician–– gynecologist receive most or all of their medical caregynecologist receive most or all of their medical care from that physician onlyfrom that physician only •• Malpractice for obstetrics practice up toMalpractice for obstetrics practice up to $100,000+ per year depending on location$100,000+ per year depending on location −− Hawaii: $40,000Hawaii: $40,000--80,000 per year80,000 per year
  44. 44. Prematurity, Prenatal Care, and Teen birthPrematurity, Prenatal Care, and Teen birth Rates in HawaiiRates in Hawaii 3.3%3.3%2.0%***2.0%***2.21%**2.21%**Teen birthTeen birth rate***rate*** 5.8%5.8%3.7%3.7%3.6%3.6%Late/no PNC*Late/no PNC* 13.3%13.3%12.8%12.8%12.2%12.2%Prematurity*Prematurity* Island ofIsland of HawaiiHawaii HawaiiHawaii StateState NationalNational *2001-2003: Peristats, March of Dimes ** Births for teens age 17 and under in 1999-2004 (derived from State of Hawaii Primary Needs Assessment Data Book 2005, Faily Health Services Division, Hawaii Dept. of Health ***Birth data for 15-17 year olds 2004 (derived from National Vital Statistics Report Website)
  45. 45. Deliveries per Year: OahuDeliveries per Year: Oahu •• Queens Medical CenterQueens Medical Center –– approximately 2200 deliveries per yearapproximately 2200 deliveries per year •• Kapi’olaniKapi’olani Medical CenterMedical Center –– approximately 5000approximately 5000--6000 deliveries per year6000 deliveries per year
  46. 46. Deliveries per Year: Maui andDeliveries per Year: Maui and Kauai, 2007Kauai, 2007 •• Maui Memorial Hospital: 1899Maui Memorial Hospital: 1899 •• Wilcox Hospital: 556Wilcox Hospital: 556 •• West Kauai Medical Center (Barking Sands):West Kauai Medical Center (Barking Sands): 240240 •• Molokai: 38 (NurseMolokai: 38 (Nurse--Midwives)Midwives) •• Lanai: Mothers asked to leave island 2 weeksLanai: Mothers asked to leave island 2 weeks prior to deliveryprior to delivery--referred to Oahu or Maui; noreferred to Oahu or Maui; no anesthesia on island; occasional unanticipatedanesthesia on island; occasional unanticipated deliveries prenatal care by two GPsdeliveries prenatal care by two GPs
  47. 47. Deliveries per Year: Island ofDeliveries per Year: Island of Hawaii, 2007Hawaii, 2007 544544Kona HospitalKona Hospital 626626North HawaiiNorth Hawaii CommunityCommunity HospitalHospital 11781178Hilo MedicalHilo Medical CenterCenter
  48. 48. Hawaii: Number of ObstetriciansHawaii: Number of Obstetricians •• Oahu: 161***Oahu: 161*** •• Island of Hawaii: 11*Island of Hawaii: 11* Hilo: 4.5Hilo: 4.5 North Hawaii: 2**North Hawaii: 2** Kona: 4.5Kona: 4.5 •• Maui: 12Maui: 12 •• Kauai: 6.5**Kauai: 6.5** *Does not include midwives **1.0 FTE locum tenems coverage **Midwives: 5, 3 do hospital work ***Hawaii ACOG Oahu Big Island Maui Kauai
  49. 49. Hawaii: Patient Population toHawaii: Patient Population to Ob/Gyn Ratio*Ob/Gyn Ratio* •• Oahu: 2,119 : 1Oahu: 2,119 : 1 •• Island of Hawaii: 5,350 : 1Island of Hawaii: 5,350 : 1 −− Hilo 7,538 : 1Hilo 7,538 : 1 −− North Hawaii 4,178 : 1North Hawaii 4,178 : 1 −− Kona 3,393 : 1Kona 3,393 : 1 •• Maui: 4,416 : 1Maui: 4,416 : 1 •• Kauai: 3,364 : 1Kauai: 3,364 : 1 *estimated women ≥ 18 y.o., however, Ob/Gyns also care for adolescent females
  50. 50. Pediatric Population, 2006Pediatric Population, 2006 < 18 yrs: 24.6%< 18 yrs: 24.6% < 5 yrs: 6.8%< 5 yrs: 6.8% U.S.A.U.S.A. < 18 yrs: 23.7%< 18 yrs: 23.7% < 5 yrs: 6.4%< 5 yrs: 6.4% KauaiKauai < 18 yrs: 23.6%< 18 yrs: 23.6% < 5 yrs: 6.6%< 5 yrs: 6.6% MauiMaui < 18 yrs: 23.4%< 18 yrs: 23.4% < 5 yrs: 6.3%< 5 yrs: 6.3% Island of HawaiiIsland of Hawaii < 18 yrs: 23.1%< 18 yrs: 23.1% < 5 yrs: 6.9%< 5 yrs: 6.9% OahuOahu < 18 yrs: 23.2%< 18 yrs: 23.2% < 5 yrs: 6.8%< 5 yrs: 6.8% Hawaii StateHawaii State U.S. Census Bureau Quick Facts
  51. 51. Factors Affecting Neighbor IslandFactors Affecting Neighbor Island Health Disparities in PediatricsHealth Disparities in Pediatrics •• Shortage of Pediatricians on neighbor islandsShortage of Pediatricians on neighbor islands •• No level II or level III nurseries, resulting in needNo level II or level III nurseries, resulting in need to transport sick babies to Oahuto transport sick babies to Oahu •• No Pediatric ICU services leading to largeNo Pediatric ICU services leading to large number of Pediatric transports to Oahunumber of Pediatric transports to Oahu •• Inadequate numbers of PediatricInadequate numbers of Pediatric--trained nurses;trained nurses; lack of adequate bed spaces for Pediatriclack of adequate bed spaces for Pediatric patientspatients •• Emergency room used as “outpatient clinic”Emergency room used as “outpatient clinic”
  52. 52. U.S. Patient to Pediatrician Ratios*U.S. Patient to Pediatrician Ratios* •• Urban areasUrban areas −− 1546 Patients: Pediatrician1546 Patients: Pediatrician •• Less populated areasLess populated areas −− 1915 Patients: Pediatrician1915 Patients: Pediatrician •• Solo PracticeSolo Practice −− 2097 Patients: Pediatrician2097 Patients: Pediatrician *Visits by patients may be nearly double number of Patients: Pediatrician Pediatric Research in Office Settings, American Academy of PediaPediatric Research in Office Settings, American Academy of Pediatrics, 1999trics, 1999
  53. 53. Hawaii: Number of PediatriciansHawaii: Number of Pediatricians •• Oahu: 233Oahu: 233--263263 •• Island of Hawaii: 23Island of Hawaii: 23 •• Maui: 20Maui: 20 •• Kauai: 8Kauai: 8 Oahu Hawaii Maui Kauai
  54. 54. Hawaii: Patients to PediatricianHawaii: Patients to Pediatrician Ratios, 2008Ratios, 2008 •• Oahu: 907:PediatricianOahu: 907:Pediatrician •• Hawaii Island:Hawaii Island: –– 1741:Pediatrician (hospitalists included)1741:Pediatrician (hospitalists included) –– 2002:Pediatrician (outpatient)2002:Pediatrician (outpatient) •• Maui: 1762Maui: 1762 patients:Pediatricianpatients:Pediatrician •• Kauai: 1866Kauai: 1866 patients:Pediatricianpatients:Pediatrician
  55. 55. Patients : PediatricianPatients : Pediatrician Island of Hawaii*Island of Hawaii* •• Hilo area:Hilo area: –– Outpatient: 2352:1 (9Outpatient: 2352:1 (9 Pediatricians)Pediatricians) –– Inpatient: 3528:1 (6Inpatient: 3528:1 (6 Pediatricians**)Pediatricians**) •• North Hawaii: 1114:1North Hawaii: 1114:1 •• Kona: 1696:1Kona: 1696:1 *Only includes physicians working ≥ 50% ** Three community physicians still doing hospital work; three hospitalist Pediatricians, two hired by HMC, including one locums tenens physician; long-term plan for HMC hospitalists to also provide outpatient care •• HiloHilo −− Pediatricians: 12Pediatricians: 12 •• North HawaiiNorth Hawaii −− Pediatricians: 5Pediatricians: 5 •• KonaKona −− Pediatricians: 6Pediatricians: 6
  56. 56. Hawaii: Age of PediatriciansHawaii: Age of Pediatricians •• Island of HawaiiIsland of Hawaii –– 26% (6/23) over age 5526% (6/23) over age 55 –– 50% (10/20) over age 5050% (10/20) over age 50 •• MauiMaui –– 50% (10/20) over age 5050% (10/20) over age 50 –– 25% (8/20) over age 5525% (8/20) over age 55 •• Kauai: 8Kauai: 8 –– 50% (4/8) over age 5550% (4/8) over age 55 •• Recruitment of new Pediatricians difficultRecruitment of new Pediatricians difficult
  57. 57. Hawaii Island Insurer Distribution, 2003Hawaii Island Insurer Distribution, 2003 Data analysis of Big Island Newborns atData analysis of Big Island Newborns at KapiolaniKapiolani Medical Center: 50% QuestMedical Center: 50% Quest
  58. 58. Neonatal and Pediatric TransportsNeonatal and Pediatric Transports from the Island of Hawaii 2007from the Island of Hawaii 2007 KapiolaniKapiolani Medical Center Transport Team dataMedical Center Transport Team data 52%52%10210260%60%7373BI TotalBI Total 1%1%171718%18%2222KonaKona 10%10%202010%10%1212N. HawaiiN. Hawaii 33%33%656533%33%3939HiloHilo % NI% NI TransportsTransports PediatricPediatric% NI% NI TransportsTransports NeonatalNeonatalLocationLocation
  59. 59. Neonatal and Pediatric TransportsNeonatal and Pediatric Transports from Other Neighbor Islands 2007from Other Neighbor Islands 2007 KapiolaniKapiolani Medical Center Transport Team dataMedical Center Transport Team data 3.5%3.5%771.7%1.7%22MolokaiMolokai 0%0%000.8%0.8%11LanaiLanai 25%25%484826%26%3131MauiMaui 19%19%383811%11%1313KauaiKauai % NI% NI TransportsTransports PediatricPediatric% NI% NI TransportsTransports NeonatalNeonatalLocationLocation
  60. 60. Hawaiian Monk Seal
  61. 61. Projected U.S. Physician ShortageProjected U.S. Physician Shortage
  62. 62. Physician/Provider Shortages MatterPhysician/Provider Shortages Matter •• Diminished capacity for disease prevention,Diminished capacity for disease prevention, screening, early diagnosis & treatmentscreening, early diagnosis & treatment •• Higher emergency room utilizationHigher emergency room utilization •• Higher hospitalization rateHigher hospitalization rate •• More intense treatmentMore intense treatment •• Higher cost to theHigher cost to the systemsystem •• Less healthy populationLess healthy population
  63. 63. Physician Shortage problem hasPhysician Shortage problem has Several ComponentsSeveral Components •• Absolute number of physiciansAbsolute number of physicians •• MalMal--distribution of physicians, indistribution of physicians, in particular the neighbor islandsparticular the neighbor islands shortageshortage •• Physician specialty mixPhysician specialty mix −− Example: HawaiiExample: Hawaii’’s loss of orthopedics loss of orthopedic surgeons across the whole statesurgeons across the whole state including Oahuincluding Oahu •• Services providedServices provided
  64. 64. Supply FactorsSupply Factors •• Aging of the workforce (1/3 > 55 in U.S., 47% >Aging of the workforce (1/3 > 55 in U.S., 47% > 50 in Hawaii)50 in Hawaii) −− Earlier retirementEarlier retirement −− MassMass ““BoomerBoomer”” retirementretirement •• Productivity influencesProductivity influences −− GenerationalGenerational −− Gender relatedGender related −− Age relatedAge related −− Insurance reimbursement issuesInsurance reimbursement issues •• Liability issues contribute to shortageLiability issues contribute to shortage •• AAMC proposes to increase U.S. medical schoolAAMC proposes to increase U.S. medical school enrollment by 30% by 2015enrollment by 30% by 2015 −− Takes up to14 years of education to produce aTakes up to14 years of education to produce a practicing physicianpracticing physician •• NonNon--physician clinicians: Physician Assistants,physician clinicians: Physician Assistants, Nurse Practitioners, Nurse Midwives, etcNurse Practitioners, Nurse Midwives, etc
  65. 65. Demand FactorsDemand Factors •• Growing populationGrowing population −− U.S. population expected to grow by 12% byU.S. population expected to grow by 12% by 20202020 −− Hawaii: Big Island expected to grow by 35% byHawaii: Big Island expected to grow by 35% by 20202020 •• Aging of the populationAging of the population −− More patient visits and chronic diseaseMore patient visits and chronic disease •• Rising expectations of patientsRising expectations of patients •• Increasing wealthIncreasing wealth •• Increasing incidence of lifestyleIncreasing incidence of lifestyle--relatedrelated chronic diseaseschronic diseases
  66. 66. Physician RecruitmentPhysician Recruitment Limiting FactorsLimiting Factors •• Need for a sufficient caseload (i.e.Need for a sufficient caseload (i.e.-- population size) to provide a financial basepopulation size) to provide a financial base •• Professional satisfactionProfessional satisfaction −− interesting cases/proceduresinteresting cases/procedures −− peer contact and interactionpeer contact and interaction •• Reasonable lifestyleReasonable lifestyle −− reasonable frequency of callreasonable frequency of call −− adequate vacation/offadequate vacation/off--time coveragetime coverage
  67. 67. Barriers to Physician RecruitmentBarriers to Physician Recruitment •• Burden on generalists to practice without specialistsBurden on generalists to practice without specialists •• Generalists work harder for the same reimbursementGeneralists work harder for the same reimbursement •• New physicians are not prepared for rural practiceNew physicians are not prepared for rural practice •• Geography and traffic are barriers to multiple officesGeography and traffic are barriers to multiple offices •• Call burden is overwhelmingCall burden is overwhelming •• Lack of financial security (income vs. cost of living)Lack of financial security (income vs. cost of living) •• Family responsibilities (spousal employment andFamily responsibilities (spousal employment and education choices)education choices) •• Limited professional community/peer interactionLimited professional community/peer interaction •• Older healthcare facilities/hospitalsOlder healthcare facilities/hospitals •• Patient transfer is difficultPatient transfer is difficult
  68. 68. Possible SolutionsPossible Solutions Multipronged ApproachMultipronged Approach •• No one simple “solution” will “work”, must useNo one simple “solution” will “work”, must use multipronged approach to this complex problemmultipronged approach to this complex problem •• No statewide planNo statewide plan −− All stakeholders should assess the needs and discussAll stakeholders should assess the needs and discuss a statewide plan, assessment/outcomesa statewide plan, assessment/outcomes −− Must include clinicians, those who take care ofMust include clinicians, those who take care of patients with real world experiencepatients with real world experience −− Physicians particularly from neighbor islands andPhysicians particularly from neighbor islands and those specialties particularly affected by the shortagethose specialties particularly affected by the shortage −− LawmakersLawmakers −− Relevant physician, public health, community,Relevant physician, public health, community, physician extenders, medical school, residencyphysician extenders, medical school, residency program and othersprogram and others
  69. 69. How Health Insurance Reimbursements HurtHow Health Insurance Reimbursements Hurt Physician Recruitment/Retention and Primary CarePhysician Recruitment/Retention and Primary Care •• For the same service (e.g.For the same service (e.g.-- hysterectomy) physicianshysterectomy) physicians receive varied fees across the country, as well as differingreceive varied fees across the country, as well as differing amounts within the same state by the same insuranceamounts within the same state by the same insurance company for the same procedurecompany for the same procedure •• Hawaii reimbursement rates said to be at least oneHawaii reimbursement rates said to be at least one--fourthfourth to oneto one--third lower than California ratesthird lower than California rates −− If physician can earn significantly more for the same workIf physician can earn significantly more for the same work elsewhere, this makes recruitment very difficultelsewhere, this makes recruitment very difficult −− Frustrates physicians who practice here, and they leave HawaiiFrustrates physicians who practice here, and they leave Hawaii •• Example: cited by orthopedic surgeons as one of the main reasonExample: cited by orthopedic surgeons as one of the main reasonss for leaving Hawaiifor leaving Hawaii •• Reimbursement issues may also affect choice of specialty,Reimbursement issues may also affect choice of specialty, and may be one of the reasons medical students are notand may be one of the reasons medical students are not choosing primary carechoosing primary care −− In most countries, 70In most countries, 70--80% of all doctors are primary care80% of all doctors are primary care physicians, but in the U.S., it is almost the oppositephysicians, but in the U.S., it is almost the opposite
  70. 70. American College of Obstetricians and GynecologistsAmerican College of Obstetricians and Gynecologists National Survey, 2006National Survey, 2006 •• Increasing malpractice insurance premiums and fear ofIncreasing malpractice insurance premiums and fear of lawsuits continue to change how medicine is practicedlawsuits continue to change how medicine is practiced −− 70% of Ob70% of Ob--GynsGyns changed how they practice due to the lack ofchanged how they practice due to the lack of available or affordable insuranceavailable or affordable insurance −− 65% made changes due to the fear of liability claims65% made changes due to the fear of liability claims •• 77--8% have stopped practicing obstetrics because of8% have stopped practicing obstetrics because of insurance affordability or fear of litigationinsurance affordability or fear of litigation −− Average age stopped obstetrics: 48Average age stopped obstetrics: 48 y.oy.o •• 89% have had at least one liability claim filed against89% have had at least one liability claim filed against themthem −− Average of 2.6 malpractice suitsAverage of 2.6 malpractice suits −− In the last three years, 55% were sued at least onceIn the last three years, 55% were sued at least once −− 70% of claims were either dropped by the plaintiff, dismissed or70% of claims were either dropped by the plaintiff, dismissed or settled without paymentsettled without payment
  71. 71. Malpractice Insurance ReformMalpractice Insurance Reform oror “Why Doctors are Heading for Texas”“Why Doctors are Heading for Texas” Over the past three years, some 7,000Over the past three years, some 7,000 M.D.sM.D.s have flooded into Texas, manyhave flooded into Texas, many from Tennessee... Why? Two words: Tort reform.from Tennessee... Why? Two words: Tort reform. In 2003 and in 2005, Texas enacted a series of reforms to the stIn 2003 and in 2005, Texas enacted a series of reforms to the state's civilate's civil justice system. They are stunning in their success. Texas Medicajustice system. They are stunning in their success. Texas Medical Liabilityl Liability Trust, one of the largest malpractice insurance companies in theTrust, one of the largest malpractice insurance companies in the state, hasstate, has slashed its premiums by 35%, saving doctors some $217 million ovslashed its premiums by 35%, saving doctors some $217 million over fourer four years. There is also a competitive malpractice insurance industryears. There is also a competitive malpractice insurance industry in Texas,y in Texas, with over 30 companies competing for business. This is driving rwith over 30 companies competing for business. This is driving rates down.ates down. The result is an influx of doctors so great that recently the StThe result is an influx of doctors so great that recently the State Board ofate Board of Medical Examiners couldn't process all the new medicalMedical Examiners couldn't process all the new medical--license applicationslicense applications quickly enough. The board faced a backlog of 3,000 applications.quickly enough. The board faced a backlog of 3,000 applications. To handleTo handle the extra workload, the legislature rushed through an emergencythe extra workload, the legislature rushed through an emergency appropriation last year.appropriation last year. Now many of the newly arriving doctors are heading to rural or uNow many of the newly arriving doctors are heading to rural or underservednderserved parts of the state. Four new anesthesiologists have headed to Beparts of the state. Four new anesthesiologists have headed to Beaumont,aumont, for example. Meanwhile, San Antonio has experienced a 52% growthfor example. Meanwhile, San Antonio has experienced a 52% growth in thein the number of new doctors.number of new doctors. Wall Street Journal, May 17, 2008
  72. 72. Hawaii Medical Students and ResidentsHawaii Medical Students and Residents State RankingsState Rankings •• Hawaii ranks 5Hawaii ranks 5thth in % who graduated from ain % who graduated from a medical or osteopathic school in that state andmedical or osteopathic school in that state and are active MDs in that state (52.8%, Stateare active MDs in that state (52.8%, State median: 39.7%)median: 39.7%) •• Hawaii ranks 41Hawaii ranks 41stst in % who completed residencyin % who completed residency in that state and are active MDs in the samein that state and are active MDs in the same state (37.5%, State median: 45%)state (37.5%, State median: 45%) •• Hawaii ranks 1Hawaii ranks 1stst in % who completed bothin % who completed both medical school and residency in that state andmedical school and residency in that state and are active MDs in the same state (83.5%, Stateare active MDs in the same state (83.5%, State median: 67.3%)median: 67.3%) 2007 State Physician Workforce Databook, AAMC
  73. 73. Influence of Student Loan Debt onInfluence of Student Loan Debt on Career ChoiceCareer Choice Salter and Kimball, J Am Acad Dermatol. 2006 Incentive to practice in underserved areas: Debt payment? Medical school tuition “payback” via years of service?
  74. 74. Effect of Birth Origin County on RuralEffect of Birth Origin County on Rural Practice, 2006Practice, 2006 Figure. Impact of birth origin county on rural practice of the 2006 physician workforce. Am Family Physician, July 2007
  75. 75. Rural Residency rotations/tracksRural Residency rotations/tracks and Career Choicesand Career Choices •• Texas Rural Family Medicine Track (Nash, Tex MedTexas Rural Family Medicine Track (Nash, Tex Med 2008)2008) −− As of 2007, 6 out of 7 residents who completed the program areAs of 2007, 6 out of 7 residents who completed the program are practicing in rural areaspracticing in rural areas •• Graduates of northern Ontario family medicine residencyGraduates of northern Ontario family medicine residency programs practice where they train (programs practice where they train (HengHeng,, Can J RuralCan J Rural MedMed 2007)2007) −− Rural residency program graduates were 4.56 times more likelyRural residency program graduates were 4.56 times more likely to practice in a rural areato practice in a rural area •• New Mexico mailed 1,396 surveys (59% response rate)New Mexico mailed 1,396 surveys (59% response rate) to health professional graduatesto health professional graduates −− Size of childhood town, rural practicum completion, discipline,Size of childhood town, rural practicum completion, discipline, and age at graduation were significantly associated with ruraland age at graduation were significantly associated with rural practice choicepractice choice Establish Hawaii Residency Program rotations on neighbor islands?
  76. 76. Other IssuesOther Issues •• Tax incentives or other incentives for underserved/ruralTax incentives or other incentives for underserved/rural physician practicephysician practice •• Establish telemedicine lines/usage to easily consultEstablish telemedicine lines/usage to easily consult specialists on Oahu from their officesspecialists on Oahu from their offices −− Insurance reimbursement for telemedicineInsurance reimbursement for telemedicine •• Hospitals in underserved areas need to change/improveHospitals in underserved areas need to change/improve to keep physicians or they will leave the areato keep physicians or they will leave the area −− Closely involve physicians in improvementsClosely involve physicians in improvements •• “New” paradigm“New” paradigm −− Use of physician extenders/nonUse of physician extenders/non--physician cliniciansphysician clinicians −− Graduates of Physician Assistant and Nurse PractitionerGraduates of Physician Assistant and Nurse Practitioner programs have been increasing over the past ten yearsprograms have been increasing over the past ten years −− Team approach: the Medical HomeTeam approach: the Medical Home

×