primary care physician scan in georgia: 2014 recruitment, retention, and coordination
TRANSCRIPT
Primary Care Physician Scan in Georgia: 2014RECRUITMENT, RETENTION, AND COORDINATION
Physician To Population Ratio
The state ranked 39th in the ratio of doctors per 100,000 population in 2010, the latest year for which data are available. That’s a slight improvement from Georgia’s 40th-place ranking in 2008.
Georgia’s Medical Workforce:Geographic
159 Counties:◦6 without a Family Physician◦31 without a General Internist◦63 without a Pediatrician◦79 without an OB/GYN◦66 without a General Surgeon
◦ Source: GBPW, 2014
Snapshot of Georgia: Race(Source: GBPW, 2007)
General Population: %
White
Black
Asian
Hipsanic
Other
Physician Workforce: %
White
Black
Asian
Other
Snapshot of Georgia: Gender (Source: GBPW, 2007)
General Population: %
Female
Male
Physician Workforce: %
Female
Male
To make a physician… The physician education pipeline is quite long
◦(K-12 education)◦4 years of undergraduate education◦4 years of medical school◦3-8 years of residency training
11-16 YEARS POST HIGH SCHOOL TO EDUCATE A NEW DOC!
PHASES OF MEDICAL EDUCATION
PHASE 1 PHASE 2 PHASE 3 PHASE 4 PRE-
MATRICULATION (middle – high
school)
UNDERGRADUATE BACCALAUREATE
Years
MEDICAL SCHOOL
RESIDENCY / GME
AHEC roles across the Pipeline: Phases 1 and 2
PREMATRICULATION: K-12; UNDERGRADUATE/BACCALAUREATE YEARS
FOCUS: Recruitment and exposure of youth to variety of health careers available and the requirements to pursue each one; working with high school and college counselors to equip them with knowledge and resources to effectively advise students.
STRATEGIES:◦ General Classroom presentations◦ Intensive health career camps and programs (20+ hours)◦ Shadowing opportunities◦ Counseling 1:1◦ Publication and dissemination of the Health Careers Manual◦ Production of Health Career videos for classroom use
SUMMARIZED OUTCOMES (FY 14):• Exposed 27,558 youth to health career opportunities through 755 regional AHEC activities and programs • Supported 1,069 students in intensive health career programs
Do we have enough physicians in the pipeline to meet our need?- Factors to consider
oImpact of ACAoNumber and training of medical school graduates in GeorgiaoGME programs in Georgiao-the “lowest hanging fruit” results from changes in Phases 3 and 4
Impact of the ACA
The Effects of Expanding Primary Care Access for the Uninsured: Implications for Health Workforce
under Health ReformAcademic Medicine, Vol. 88, No. 12/ December 2013
“Meeting the workforce demands of the newly insured under new coverage programs… may require new processes of care,
realignment of patient and providers, changes in the roles of physicians and other providers, and modifications to how health
care providers are trained and care is led.”
Older students, female students, and students from minority backgrounds are more likely to enter PC and / or to practice in underserved areas
Students with rural backgrounds are more likely to practice in rural areas
Challenges and Opportunities in Building a Sustainable Rural Primary Care Workforce in Alignment with the Affordable Care Act
Academic Medicine, Vol. 88, No. 12/ December 2013
“With expanded health care access for patients, primary care physicians, PA’s and NP’s will be in even greater demand than in
the past. “
HRSA: Projected Demand for Primary Care
Physicians 2010 2020
Total primary care physician demand (FTE)
212,500a 241,200
Generalb 164,400 187,300Pediatrics 44,800 49,600Geriatrics 3,300 4,300
Primary care physician supply
205,000 220,800
Supply and demand (7,500) (20,400)
a National demand projections presented in this report assume that in 2010 the national supply of primary care physicians was adequate except for the approximately 7,500 FTEs needed to de-designate the primary care HPSAs.bThis category includes general and family practice, and general internal medicine.
NACHC Access 2015: Georgia Goals
Georgia Medically Disenfranchised = 1,335,787
Access 2015 Goal (25%) = 333,947
CHC patients 2006 = 248,205
Anticipated CHC patients 2015 = 582,152
How many Primary Care providers will we need?
To cover CHC increaseNeed 88 new PA / NPNeed 168 new Primary Care Physicians
To cover all 1,335,787
Need 351 new PA/NP Need 676 new Primary Care Physicians
Access Transformed -Building a Primary care Workforce for the 21st Century; NACHC, Robert Graham Center, George Washington University School, 2010
oNumber and training of medical school graduates in Georgia
Number and training of medical school graduates in Georgia
Quick Scan of Key MeasuresMedical Student Debt and Primary Care Income
Medical Schools in Georgia: 2014
SCHOOL ANNUAL TUITION ESTIMATED # OF STUDENTS (2011-2012)
TOTAL TUITION COSTS
EMORY 45,000 518 23,310,000
MCG 24,726 852 21,066,552
MERCER 41,457 387 16,043,859
MOREHOUSE 36,903 230 8,487,690
GA-PCOM 40,812 390 15,916,680
TOTAL 2377 $84,824,781
Bottleneck: Community Based Training Sites to support core clerkships
MEDICAL STUDENTS: Each medical student has approximately 7 required core clerkship rotations in their third year. (Family Medicine, Internal Medicine, Pediatrics, Emergency Medicine, OB/GYN, Psychiatry, and General Surgery)
◦ Each rotation lasts 4-6 weeks on average.◦ Approximately 40% of these required clerkship rotations occur in community based settings with non-
compensated volunteer faculty;◦ In 2012, there were approximately 594 3rd year Georgia Medical Students at our five schools◦ 594 x 7 required core clerkships = 4,158 rotations; ◦ 4,158 x 40% in community settings = 1,663 rotations in uncompensated community sites◦ In 2020 it is estimated that Georgia will have 803 3rd year medical students needing +/-3,212 off campus
community based training with a CBF member.
AHEC roles across the Pipeline: Phase 3
MEDICAL SCHOOL YEARS
FOCUS: Support student rotations in community based settings remote from home campus, to expose students to rural areas and AHEC regions and to develop relationships with students for eventual recruitment into the host regions.
STRATEGIES:◦ Locate / partner with appropriate community based training sites and assist with academic credentialing of providers to become
community based faculty◦ Provide preceptor faculty development programs and trainings◦ Provide Housing for students on rotations remote from their campus◦ Provide travel assistance to students on rotations remote from their campuses◦ Manage the flow of students into practices to prevent chaos
SUMMARIZED OUTCOMES (FY 14): • Worked with 1,257 community based faculty clinical preceptors• Supported travel and housing for 2,573 health profession student rotations • Worked with 2,803 health professions students in 4,153 rotations in clinical training sites for a total of 656,072 training hours• Implementing PTIP
Driving forces against PC choices by medical students
1. Primary Care physicians continue to make approximately 50% of what a specialist makes even though their debt load is the same.
2. The interest accrued from Government student loans generated $66 billion between 2007-2012. (recently released report from the GAO, 2014)
3. Current medical student loans are provided with interest rates of approximately 6.8%- 7.9%.
4. The average medical student debt is $170,000; according to the AAMC a doctor owing $175,000 at graduation can end up repaying more than $300,000 once interest is factored in.
National Medical Student Debt (NEJM, 2008)
* Estimated at $145,000 for public and $180,000 for private medical school graduates
* Total medical student debt estimated at $2 billion per year * The federal “cash for clunkers” program cost $2 billion per
month * If medical school tuition was made free, it would cost approximately $2.5 billion per year
◦ ( Bach and Kocher, New York Times article, 5/28/11)
Can Medical Students Afford to Choose Primary Care? (Academic Medicine, January 2013)
“Graduates pursuing primary care with higher debt levels ($250,000-$300,000) need to consider additional strategies to support
repayment… use of federal loan forgiveness…”
Students entering now will graduate over $250,000 in debt.In Georgia, tuition increases in last 5 years:Emory $34,205 to $42,000 22.7%MCG $10,772 to $21,408 98.7%Mercer $27,876 to $39,885 39.5%Morehouse $22,500 to $29,484 31.1%PCOM $38,100
DEBT DISCOURAGES PRIMARY CARE GME
Potential Strategies: Phase 3 Reduction of interest rates on medical school debt Reduction in tuition costs Full/ partial loan repayment / start in residency years for PC Free medical school tuition for primary care Free medical school tuition for all
GME programs in Georgia
Quick Scan of Key MeasuresUpdate on GME in Georgia, courtesy of the Georgia Board for Physician Workforce, April 2014 report
Off Shore Medical Graduates and GME: Selected Facts and Figures
◦ Data is sketchy at best, but we do know that IMG are contributing to the physician workforce in the US and in Georgia.
◦ According to the office of Senator Richard Durbin (Illinois), Caribbean Medical Schools received over $450 million in US Department of Education Title IV funding in 2013.
◦ Texas, during the 2013 Legislative session, passed a law barring foreign medical schools from buying up core clinical training spots at Texas teaching hospitals and institutions.
◦ IMGs constitute approximately 25% of the US physician workforce and approximately 29% of US physician residency training program slots.
◦ IMGs are required to complete residency training in the US and most enter the country on J-1 visas whose holders are required to leave the US for 2 years before they return. The exception is under the Conrad J-1 visa waiver which allows state health departments to request 30 visa waivers annually for IMGs working for approved employers.
◦ 31.3% of Georgia GME graduates in 2013 attended medical school in another country.
Growing Imbalance of Med Ed System◦ UME expansion is occurring at nearly double the rate of GME
◦ Georgia ranks 39th in total residents per capita
◦ GA rate is 20.8/100,000; National rate is 35.7/100,000
◦ Per capita growth in GME capacity has been minor in last 10 years
◦ Georgia needs 1,450 more positions to match the US average (or 315 to meet SE average)
Bottom Line: The lack of GME positions is forcing students out of state to complete training, decreasing the likelihood that they will practice in Georgia
Source: Graduate Medical Education Data Resource Book; ACGME,2010
Origins of GME Crisis in Georgia• Medicare GME Capped (12/31/96 -BBA 1997)
• 1990-2010 Georgia grew 6.4-9.7 M +77%• 1990-2010 USA grew 248-308 M +36%
• New England has all states with > 50 residents/100,000
• Georgia is capped at 20.8 residents/100,000
New England 350 Physician/100,000 Georgia 200 Physician/100,000
GME and GME Graduates
Data Brief, March 2013, Georgia Board Physician Workforce, 2012
Key Findings:
•50.0% of GA GME graduates are remaining in Georgia to practice
•Existing GME programs in GA have experienced a 17.6% decrease in state funding since 2009
•In 10 years, the percent of graduates with debt over $200,000 has increased from 3% to 30%
•The average starting salary of respondents entering primary care was $168,280; the average for all other specialties was $231,318
• Average starting salary for pediatrics was $135,125
• Average starting salary for cardiovascular surgeons was $321,000
SO WHAT DO WE NEED TO DO?
CONFRONTING GEORGIA’S HEALTH WORKFORCE SHORTAGES
STRATEGIES AND OPPORTUNITIES
Remove or adjust the GME caps imposed by the Balanced Budget Act Immediately open new GME slots in areas of population growth Increase federal and state loan repayment programs for PC residents and graduates Increase # of PC residency slotsProtect existing residency programs from funding cuts and recognize the number of unfunded (over the cap) slots programs are supporting Address payment differentials immediately Implement rural / primary care admissions tracks and curriculum at our medical schools
2014 GAINS
Increase the number of GME Loan Forgiveness Awards AND the amount of each award, as administered by the Georgia Board for Physician Workforce.
STATUS: The GBPW budget was increased to provide 10 additional GME Loan Forgiveness Awards at the $20,000/year level. While the awards were not increased to the $30,000 level requested, the new funds do provide for an increase from 16 to 26 awards.
Support the Board of Regents request for $3,225,000 in new funds to support creation of new residency slots in Georgia
STATUS: The Conference Committee elected to provide $2,000,000 for this initiative in FY 2015.
Support the Georgia Board for Physician Workforce proposal to increase primary care residency capitation funds by $3,489,440 for new and expansion positions in the FY 15 budget
STATUS: Increase all Georgia Board for Physician Workforce capitation residency grants by $333 in state funds ($498,168); most of these will qualify for federal match.
Revising the powers of the GBPW as it relates to medical student scholarships
STATUS: HB 998 passed which revises the powers of the Georgia Board for Physician Workforce as it relates to medical student scholarships. This provides expanded latitude for the GBPW to establish population and specialty rules based on the needs of the state without seeking legislative changes.
Increasing housing resources for AHEC
The 2014 Legislature provided an additional $300,000 for FY 15 to the Statewide AHEC Network to support housing to support community based clinical training.
This has already resulted in an increase of housing sites and housing beds within these sites.
FY 2014 FY 2015 % CHANGE
NUMBER OF COUNTIES
25 29 14%
NUMBER OF BEDS 180 212 15%
Provide tax deductions for community based faculty precepting 3rd and 4th year Georgia medical students (SB 391)
SB 391 was passed creating the first community based faculty tax deduction in the country. Off-shore and out-of-state medical schools are using Georgia CBF and paying them +/-$1500 per rotation. Rather than engaging in a bidding war, the tax deduction is a proactive strategy to provide a powerful incentive to Georgia CBF to take Georgia Medical, Physician Assistant, and Nurse Practitioner students.
PTIP UPDATE
Eligible Programs: Physician
Emory University School of Medicine
Medical College of Georgia (Georgia Regents University)
Mercer University School of Medicine
Morehouse School of Medicine
Philadelphia College of Osteopathic Medicine, Georgia Campus
Eligible Programs: Physician Assistant
Emory University PA Program
Georgia Regents University PA Program
Mercer University PA Program
South University PA Program
PCOM-GA Campus PA Program
Eligible Programs: Nurse Practitioner
Albany State University
Armstrong Atlantic University
Brenau University
Emory University
Georgia College and State University
Georgia Regents University
Georgia Southern University
Georgia State University
Kennesaw State University
Mercer University
University of North Georgia
Valdosta State University
Certification The Statewide Area Health Education Centers Program Office at Georgia Regents University shall administer the program and certify rotations for the department.
Individual academic programs will report completed qualifying rotations to the Statewide AHEC Program Office
GA-PTIP Website: www.gru.edu/ahec/ptip
Will be live by mid-September Will feature two online reporting portals:
◦ Physician Registration◦ Program Reporting
Will provide FAQs, Eligibility Guidelines, Training Opportunities, Program Guidelines, News and Updates
Statewide AHEC Program Office
* Will maintain website and portals * Data will be summarized at the Statewide AHEC Program Office
* Tax Deduction Certification letters will be issued by the Program Office in January of each year for the last full
calendar year * Provide a report to the Legislature each year
CONTACT ME DENISE D. KORNEGAY, MSW
Associate Dean, Area Health Education Centers
Associate Professor, Department Of Family Medicine
Medical College Of Georgia
Georgia Regents University
706-721-8557
[email protected] www.gru.edu/ahec