women's access to healthcare - adrienne zertuche presentation
TRANSCRIPT
Georgia’s Obstetric Crisis:Origins, Consequences, and Potential Solutions
Georgia Senate Study Committee on Women’s Adequate Healthcare
Monday, October 26, 2015
Adrienne D. Zertuche, MD, MPHGeorgia Maternal and Infant Health Research Groupof the Georgia Obstetrical and Gynecological Society
Outline
Overview
Origins
Consequences
Potential Solutions
2
Georgia’s Obstetric Care Crisis
3
5
55
Ob Care in Rural Georgia
43 of the 82 Georgia PCSAs* outside of the Atlanta MSA (52%) have either an overburdening
or a complete absence of obstetric providers
No obstetricians: 31 (38%) No delivering family practitioners: 73
(89%) No certified nurse midwives: 57 (70%)
4
* Primary Care Service Area: collection of counties in which >30% of those county residents receive their primary care
* Georgia Board for Physician Workforce. Physician Workforce Resource Center..
5Status of Obstetric Services in
Georgia (by PCSA)
Dec. 2011
On average, men stop practicing obstetrics at age 52, and women at age 44.*
<45 45-49.9 50-54.9 >550
5
10
15
2033% 35%
19%13%
Average Ob Age in Rural PCSAs
Average Obstetrician Age
No.
of R
ural
PC
SA
s
≥
6Retirement of Rural Obs
* Rayburn WF and ACOG. The Ob/Gyn Workforce in the United States, 2011.
Future of Ob Care
43 of the 82 Georgia PCSAs outside of the Atlanta MSA (52%) have either an overburdening or a
complete absence of obstetric providers
In 16 of 47 rural PCSAs with obstetric providers (35%), ≥50% of physicians will discontinue care within 5 to 10 years
By 2020, 58 of 77 rural PCSAs (75%) will lack adequate obstetric services
7
Origins
8
5
55
Origins of Ob Care Crisis
Provider Trainees
Obstetricians
Birthing Facilities
Financial Realities
9
Provider Trainee Survey10
Emory
Ob/Gyn Residents (N=95)
84.2% Response Rate (n=80)
CNM Students (N=28)100% Response Rate (n=28)
38%63%
High School
43%
57%
Medical School
GeorgiaElsewhere
91%
9%
FemaleMale
Ob/Gyn Residents11
82%
18%
Nursing School
GeorgiaElsewhere
25%
75%
High School
96%
4%
FemaleMale
CNM Students12
Emory
Yes No Unsure0
5
10
15
20
25
30
35
40
45
28% 28%
44%
Staying in Georgia13
Yes No Unsure0
5
10
15
32%36%
32%
Ob/Gyn Residents CNM Students
Will you stay in Georgia upon completion of your training?
Rural / Shortage Areas14
Ob/Gyn Residents CNM Students
How likely are you to practice in one of Georgia’s rural/shortage areas?
Extremely
Likely
Likely
Unlikely
Extremely
Unlik
ely0
5
10
15
20
25
30
35
40
45
3%
22%
46%
29%
Extrem
ely Lik
elyLik
ely
Unlike
ly
Extrem
ely Unlik
ely0
5
10
15
18%
36%46%
0%
Likely Unlikely0
5
10
15
20
25
30
35
40
45
Ob > GynOb < GynNo Preference
CNM Students
Practice Preference15
Ob/Gyn Residents
How likely are you to practice in one of Georgia’s rural/shortage areas?
p = 0.01 p = 0.06
Likely Unlikely0
5
10
15
Ob > GynOb < GynNo Preference
Georgia Ties16
Ob/Gyn Residents CNM Students
How likely are you to practice in one of Georgia’s rural/shortage areas?
Likely Unlikely0
5
10
15
20
25
30
35
40
45
Georgia Tie(s)No Georgia Tie(s)
Likely Unlikely0
5
10
15
Georgia Tie(s)No Georgia Tie(s)
p = 0.13 p = 0.15
Debt Burden17
CNM StudentsOb/Gyn Residents≤$99,999 $100,000-199,000 ≥$200,000
0
5
10
15
20
25
30
35
40
45
25% 25%
50%
≤$99,999 $100,000-199,000 ≥$200,0000
5
10
15
20
25
71%
25%
4%
2006 2009 2012 Current0
10
20
30
40
50
60
≤$99,999$100,000-199,999≥$200,000
Debt Trends: Residents18
Georgia Board for Physician Workforce. GME Annual Survey, compiled data 2006-2012.
Likely Unlikely0
10
20
30
With financial incentiveWithout fi-nancial in-centive
Likely Unlikely0
10
20
30
40
50
60
70
With financial incentiveWithout fi-nancial in-centive
Financial Incentives19
CNM StudentsOb/Gyn Residents
How likely are you to practice in one of Georgia’s rural/shortage
areas?
p < 0.001 p < 0.001
Financial incentives include loan repayment, tax credits, guaranteed salary, differential pay, support to open own practice, and higher
Medicaid reimbursement rates
Obstetricians
Quality of life
Demanding call schedules Departure of other local physicians
20
5Moultrie“We are the only obstetrical practice in town. With one OB and a midwife, we did 550 deliveries last year. Sometimes we see 60 women in a day. 75 to 80 percent of our patients are Medicaid. It’s difficult to recruit physicians of any kind to this area.”
5Waycross“There were only 2 OBs in Waycross when I [left] the state. They need 4 to adequately take care of all the women in the community.”
Birthing Facility Closures
Rural Hospitals
Labor & Delivery Units
23
5Waycross“In OB, you don’t want to be too far from where you need to be.”
Labor & Delivery Closures
2012-2014
5
Labor & Delivery Closures
1994-2015
40% decline
5
Financial Realities
Malpractice insurance Retirement of obstetricians Family practitioners avoiding maternity care
Medicaid reimbursement
27
5La Grange“The paperwork kept getting more and more complicated [but] the malpractice insurance rate increase was the clincher. We stopped OB.”
5Americus“In rural Georgia, 70-80% of patients are Medicaid, and with today’s reimbursement rates, no matter how smart you run your business, it’s hard to get by.”
Consequences
30
5
55
Infant mortality:1 16th
Maternal mortality:2 2nd
1. National Women’s Law Center. www.hrc.nwlc.org. 2. Henry J. Kaiser Family Foundation. www.kff.org.
March of Dimes, Premature Birth:1
Population Institute, Reproductive Health:2
1. March of Dimes. 2014 Premature Birth Report Cards. 2. Population Institute. 2014 Reproductive Health and Rights Report Cards.
C-
D-
Perinatal Periods of Risk33
CityMatCH. Perinatal Periods of Risk. www.citymatch.org.
Rural Disparities
Rural pregnant women are at increased risk of:
Late initiation of prenatal care1
Hospitalization for pregnancy complications1
Home birth1
Low birth weight2
Neonatal mortality2
34
1. ACOG Committee Opinion 429. Obstet Gynecol, 2014.2. Larson EH, et al. Univ. of Washington Rural Health Research Center, 2008.
5
Americus“[From] Preston, it’s 30 miles to Americus. If [patients] have cars, they don’t have much gas, and there’s no public transportation. They don’t come to prenatal care.”
5Preterm Birth in Georgia
1999-2009
55
555
5
Are They Related?
Driving Time and Preterm Delivery
Controlled for maternal age, race/ethnicity, marital status, maternal education, government-assisted payment, maternal residence, birth order, prior poor infant health outcome, and transfer status
Driving Time Odds Ratio for Preterm Delivery (< 37 weeks), with 95% CI
≤ 15 minutes 1.00
16 – 30 minutes 1.06 (1.01, 1.11)
31 – 45 minutes 1.09 (1.03, 1.14)
> 45 minutes 1.53 (1.46, 1.60)
There is a spatial mismatch between a pregnant woman’s risk and her access to services
38
Driving Time and Preterm Delivery: Non-Metropolitan Georgia,
1999-2009
24% of pregnant women drove >45 minutes to access ob services
Women that drove >45 minutes were 1.5x more likely to deliver preterm than women that drove <15 minutes
Average drive times Woman that delivered preterm: 40 minutes Woman that delivered at term: 32 minutes
39
55
5
5 55
Potential Solutions
41
5
55
Potential Solutions to Crisis
Recruitment
Retention
Referral
42
Recruitment
Past Success Financial incentive programs: RPTC, PRAAP
Upcoming Challenges GME slots Applicants to medical school and residency training South Georgia CNM training program
43
Financial Incentive Programs
Rural Physician Tax Credit1
Georgia Department of Revenue Tax credit: $5,000 annually for max. 5 years
Physicians for Rural Areas Assistance Program2
Georgia Board for Physician Workforce Loan repayment: $25,000 annually, for max. 4 years or
$100,000
44
1. Georgia Dept. of Revenue. 560-7-8-.20: Rural Physician Credit, 2012.2. Tucker C. PRAAP Application. Georgia Board for Physician Workforce, 2012.
Physicians for Rural Areas Assistance Program(PRAAP)
House Bill 998 (2014)
HB 998 permits Georgia Board for Physician Workforce to adapt qualification criteria for PRAAP
Program can now include counties that have populations >35,000 but are still in need of obstetric providers
Passed March 2014 Signed into law April 2014
46
Georgia General Assembly, 2014. House Bill 998.
Retention
Past Successes Medicaid parity Increased Medicaid reimbursement for ob codes
Upcoming Challenge Medical liability reform
47
Medicaid Parity
Initially absent from Governor’s proposed budget
Appropriations amended by General Assembly House Bill 76 (2015)
$23 million (state) + ~ $46 million (federal) = full parity
48
Georgia Budget & Policy Institute. Overview: 2016 Fiscal Year for the Department of Community Health.
Medicaid Reimbursement
First increase in Medicaid reimbursement in 14 years Targeted codes for prenatal and peripartum care
49
Procedure Code Possible Fee Increase59400 – Obstetric Care $ 330
59425 – Antepartum Care Only $ 180
59426 – Antepartum Care Only $ 350
59510 – Cesarean Delivery $ 220
59610 – VBAC Delivery $ 360
59618 – Attempted VBAC Delivery $ 260
Patterson A. GOGS Newsletter, April 2015.
Referral
Past Success Perinatal Regions and Centers
Upcoming Challenges Improved regionalization
- Prenatal services
- Delivery hospitalization
Telemedicine
50
51Georgia Perinatal Regions and Centers
GOGS. Georgia’s Regional Perinatal System. www.gaobgyn.org.
Improving Regionalization
Prenatal services Sweeping reform ?
Delivery hospitalization Risk-appropriate care Assessment of service capacity
- AAP neonatal levels of care1
- ACOG/SMFM maternal levels of care2
Role of telemedicine
52
1. AAP Policy Statement. Pediatrics, 2012.2. ACOG/SMFM Obstetric Care Consensus. AJOG, 2015.
Congressional Committees
2013: Joint Study Committee on Medicaid Reform
2014: House of Representatives Study Committee on Medical Education
2015: Senate Study Committee on Women’s Adequate Healthcare
53
Summary
54
5
55
Summary
Georgia has the 2nd highest maternal mortality and 16th highest infant mortality ratio in the U.S.
Outside of Atlanta, the obstetric provider shortage is severe and getting worse, and L&D units are rapidly closing
Women that drive long distances for obstetric care are at increased risk of adverse outcomes
The Georgia General Assembly has undertaken several initiatives to improve maternal and infant health in the state, but the efforts must continue …
55
Acknowledgements
Georgia Maternal and Infant Health Research Group (GMIHRG)
Roger Rochat, MD
Andrew Dott, MD, MPH
Pat Cota, RN, MS
56
References American Academy of Pediatrics. Policy Statement: Levels of Neonatal Care. Pediatrics (2012); 130(3): 587-97.
American College of Obstetricians and Gynecologists. Committee Opinion Number 429: Health Disparities in Rural Women. Obstet Gynecol (2012); 123: 371.
American College of Obstetricians and Gynecologists / Society of Maternal-Fetal Medicine. Obstetric Care Consensus: Levels of Maternal Care. AJOG (2015); 212(3): 259-71.
Bluestein G. New Georgia abortion restrictions in doubt after judge’s ruling. Atlanta Journal Constitution. Dec 25, 2012. Accessed online July 27, 2015 at www.ajc.com.
CityMatCH. Perinatal Periods of Risk. Accessed online July 27, 2015 at www.citymatch.org.
General Assembly of Pennsylvania, 2014. Senate Bill 1456.
Georgia Board for Physician Workforce. Graduate Medical Education Annual Survey, compiled data from 2006-2012. Received from Colette Caldwell July 22, 2013.
Georgia Board for Physician Workforce. Physician Workforce Resource Center. Accessed online Oct 1, 2011 at www.gbpw.ga.gov.
Georgia Budget & Policy Institute. Overview: 2016 Fiscal Year for the Department of Community Health. Accessed online July 27, 2015 at www.gbpi.org.
Georgia Department of Revenue. 560-7-8-20: Rural Physician Credit. Accessed online Jan 1, 2012 at http://rules.sos.state.ga.us/docs/560/7/8/20.pdf.
Georgia General Assembly, 2012. House Bill 954.
Georgia General Assembly, 2014. House Bill 998.
57
References Georgia Obstetrical and Gynecologic Society. Georgia’s Regional Perinatal System. Accessed online July 27,
2015 at www.gaobgyn.org.
Henry J. Kaiser Family Foundation. State Health Facts, Infant Mortality Rate (2010). Accessed online March 13, 2015 at www.kff.org.
Larson EH, et al. Poor Birth Outcome in the Rural United States: 1985-1987 to 1995-1997. The University of Washington Rural Health Research Center; 2008.
March of Dimes. 2014 Premature Birth Report Cards. Accessed online July 27, 2015 at www.marchofdimes.com.
National Women’s Law Center. Making the Grade on Women’s Health: A National and State by State Report Card, Maternal Mortality Rate (2010). Accessed online March 13, 2015 at www.hrc.nwlc.org/states/georgia.
Ness CL and Cutler C. Mandating bad medicine. Philadelphia Inquirer. Accessed online July 28, 2014 at www.philly.com.
Patterson A. Georgia Legislation Gives OBGyns First Medicaid Increase in 14 Years. Georgia Obstetrical and Gynecologic Society Newsletter, April 2015.
Population Institute. 2014 Reproductive Health and Rights Report Cards. Accessed online July 27, 2015 at www.populationinstitute.org.
Rayburn WF and American Congress of Obstetricians and Gynecologists. The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications, 2011.
Tucker C. Application for Physicians for Rural Area Assistance Program, 2012. Georgia Board for Physician Workforce. Accessed online May 15, 2013 at www.gbpw.georgia.gov.
58
Comments or [email protected]