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Rural Health RoundtableOctober 2, 2008October 2, 2008

Robert A. Barish, M.D.Robert A. Barish, M.D.Vice Dean, Clinical AffairsVice Dean, Clinical Affairs

Professor, Emergency Medicine and Medicine, Emergency Medicine and MedicineUniversity of Maryland School of MedicineUniversity of Maryland School of Medicine

Maryland Physician Workforce StudyMaryland Physician Workforce Study

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Maryland Physician Workforce StudySteering Committee

*Robert A. Barish, M.D., ChairVice Dean for Clinical Affairs, University of Maryland School of Medicine

*John Colmers, Secretary, Dept. of Health & Mental Hygiene

*Rex W. Cowdry, M.D., Exec. Dir., Maryland Health Care Comm.

Blair Eig, M.D., VP Medical Affairs, Holy Cross Hospital

Richard Grossi, CFOJohns Hopkins Medicine

Scott Hagaman, M.D.President, MedChi

*Harry C. Knipp, M.D., ChairMaryland Board of Physicians

Scott E. Maizel, M.D.Surgery Representative

Stephen J. Rockower, M.D.Medical Specialty Representative

Joseph Twanmoh, M.D., FACEPVice President, American College of Emergency Physicians, MD Chapter

Joseph W. Zebley, III, M.D., FAAFPPrimary Care Representative

*State agency representatives participated on the Steering Committee to assist the effort without taking a position on its policy recommendations.

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Study Approach

Quantitative (Data) and Qualitative (Surveys)

Supply→Refined Licensure Data

Requirements→Population-Based Demand Benchmarks

Study Period: 2007 - 2015

Analysis of Variation by Specialty Group

Analysis for Five Maryland Health Planning Regions

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Primary Care Family Medicine

Geriatric Medicine

Internal Medicine

Pediatrics

Medical Specialty Allergy Cardiology Dermatology Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Nephrology Neurology Psychiatry Pulmonary Medicine• Rheumatology

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Hospital-Based Anesthesiology

Diagnostic Radiology

Emergency Medicine

Neonatology

Pathology

Physical Medicine

Radiation Oncology

Surgical Specialty General Surgery Neurosurgery OB/GYN Ophthalmology Orthopedic Surgery Otolaryngology Plastic Surgery Thoracic Surgery Urology Vascular Surgery

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Step 1: Calculation of Baseline Practicing Physician Supply

Federally EmployedExcept VA

1,485

Practice Site Out-of-State

4,212

Non-practicing physicians

2,664

Non-renewals1,716

Currently Licensed Physician Supply

24,968

Adjusted Baseline Physician Supply

14,891

MINUS EQUALS

Source: Maryland Board of Physicians

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Step 2: Calculation of 2007 Clinical Physician Supply

Adjusted by %Clinical Status

Adjusted Baseline Physician

Supply14,891

Adjusted byFT/PT Status

Total Clinical Physician

Supply10,227

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.

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Step 4: Forecast Physician Supply for 2010 & 2015

Clinical Physician

Supply2007

Retirements/Deaths

Gender/Lifestyle

NetIn-Migration

ResidentsRemaining

In MD

ForecastedClinical

PhysicianSupply

2010 & 2015

MINUS EQUALSPLUS

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Step 5: Calculate Impact of Residents in Graduate Medical Education Programs

Analyze resident data Adjust for work effort based on

recommendations by residency program directors:– Primary Care: 0.3 FTE– Medical Specialties: 0.3 FTE– Hospital Based Specialties: 0.15 FTE– Surgical Specialties: 0.15 FTE

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Total Clinical Physicians per 100,000 Residents by Region Compared to

State and National Levels

0

50

100

150

200

250

Capital Central Eastern Southern Western

US

MD

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Percentage of Medical Specialists Age 60 and Older by Region

2007

Medical Specialties significantly impacted by retirements (age of the workforce)

Capital and Eastern regions have highest percentage of physicians over Age 60

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Capital Central Eastern Southern Western

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Overall Observations Regarding Primary Care Requirements versus Supply

Quantitative Observations– Greatest shortages in 3 rural regions– Southern Maryland has shortages under all 3 scenarios

and decreasing resources from 2007-2015– Maryland becoming more dependent on allied health

professionals to supplement primary care physicians

Qualitative Observations by Medical Directors – Primary care cited as greatest physician recruitment

need by 43% of Medical Directors– Out-of-state recruitment increasingly difficult- (Maryland

not competitive from a compensation & cost-of-living standpoint)

– Recent graduates not selecting community-based practice

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Overall Observations Regarding Medical Specialty Requirements versus Supply

Quantitative Observations– Medical specialty shortages in 3 rural regions

– Principal statewide shortages: Dermatology, Gastroenterology, Hem/Onc & Psychiatry

– 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)

Qualitative Observations by Medical Directors – Greatest need: Gastroenterology cited by 17% of medical

directors

– Major concerns cited: Call coverage of ED & ability to replace retiring physicians

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Overall Observations Regarding Surgical Physician Requirements versus Supply

Quantitative Observations– General Surgery: Specialty with greatest need

– Downward Supply Trends 2007-2015: Forecasted in-migration and new residents insufficient to cover retirements in many surgical specialties

– Thoracic Surgery: Greatest impact from retirements

Qualitative Observations by Hospital Medical Directors

– Recruitment Priorities: (% of medical directors citing surgical needs): General Surgery (38%), Orthopedic Surgery (30%), OB/GYN (28%), ENT (23%), Neurosurgery (17%) & Vascular Surgery (17%)

– Hospital Recruitment Strategy: Pursuing employed model to address both competitive compensation & on call needs

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Future vs. Historical Trends

Major variables where change may occur:

In- and Out-Migration of Physicians Percent of medical residents staying to practice

in Maryland Physician retirement trends, especially in high

stress specialties Physician productivity Economic growth in Maryland.

Need to update physician workforce analysis every few years.

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Summary of Findings

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Maryland Physician Workforce Study – Current Physician Shortages by Region2007

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

Total8 5 18 25 20

% of Shortages27.6% 17.2% 62.1% 86.2% 69%

Legend

AdequatePhysicianSupply

Borderline PhysicianSupply

PhysicianShortage

*Physician Only **Physician & Resident Model

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Maryland Physician Workforce Study – Current Physician Shortages by Region2015

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

Total11 4 17 27 27

% of Shortages37.9% 13.8% 58.6% 93.1% 75.9%

Legend

AdequatePhysicianSupply

Borderline PhysicianSupply

PhysicianShortage

*Physician Only **Physician & Resident Model

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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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Major Conclusions. . .Maryland has a Growing

Physician Crisis

Maryland has 16 percent fewer physicians (clinical full-time equivalent) per population than the U.S.

Physician shortages are acute in most specialties in the state’s three rural regions.

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Major Conclusions. . .

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.

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Major Conclusions. . .

Critical shortages in primary care physicians and most medical specialties exist today and into 2015 in Southern Maryland, Eastern Shore, and Western Maryland.

Surgical specialties; e.g., general surgery and thoracic surgery, experiencing critical shortages.

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Major Conclusions. . . 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.

Physician workforce will experience significant retirements between 2007 and 2015; especially in medical/surgical specialties and in the Capital area.

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.

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Major Conclusions. . .

If resident in-training retention rates decrease, forecasted physician supply in 2010 and 2015 will be dramatically less . . . resulting in greater physician shortages.

In many specialties, physician in-migration plus new medical residents remaining in Maryland will not offset retirements.

National and international markets for physicians is now extremely competitive. Maryland needs to act to remain competitive.

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Recruitment and Retention: Reimbursement

POLICY RECOMMENDATIONS

Governor’s Task Force on Health Care Access and Reimbursement: Adopt recommendations to make physician reimbursement rates in Maryland nationally competitive.

Enact legislation to permit physicians to form practice associations to enhance physician recruitment efforts, improve practice efficiency, and negotiate competitive fees.

Enact legislation to require insurers to pay newly credentialed physicians retroactive to the date they applied to the payor for credentialing.

Establish enhanced Medicaid reimbursement in shortage areas similar to Medicare.

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POLICY RECOMMENDATIONSRecruitment and Retention: Medical Liability

Make Maryland competitive from a medical liability perspective with those states that are currently attracting physicians. Examples include:

– Caps on non-economic damage awards equal to Texas’s $250,000

– Alternative dispute resolution mechanisms

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POLICY RECOMMENDATIONS

State: Loan forgiveness program to attract and retain residents in rural areas with specialty shortages.

Hospitals: Loan forgiveness for residents who practice in their areas.

Maryland teaching programs: Rotations in regions/hospitals with shortages.

Gain federal support for increased access to National Health Service Corp (NHSC) physicians.

Retention of Maryland Residents in Training

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POLICY RECOMMENDATIONS

Residency program directors: Create forum to increase in-state retention of their trainees.

Develop regional capitation of some medical school slots.

GME programs: Partner with hospitals in the three rural regions to identify potential residents for positions in those areas.

Retention of Maryland Residents (Cont’d.)

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POLICY RECOMMENDATIONS

Increase the number of residency slots.

Retention of Maryland Residents (Cont’d.)

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Comments/Questions