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The Developing Crisis Rural General Surgery

The Developing Crisis Rural General Surgery. New England Rural Health Round Table October 30, 2009. Rural General Surgery. Some Headlines “Shortage of General Surgeons Endangers Rural Americans” Washington Post, January 1, 2009 “Surgeon Shortage Pushes Hospitals to Hire Temps”

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The Developing Crisis Rural General Surgery

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  1. The Developing CrisisRural General Surgery New England Rural Health Round Table October 30, 2009

  2. Rural General Surgery Some Headlines “Shortage of General Surgeons Endangers Rural Americans” Washington Post, January 1, 2009 “Surgeon Shortage Pushes Hospitals to Hire Temps” Wall Street Journal, January 13, 2009 “Experts Say Projected Surgeon Shortage a ‘Looming Crisis’ for Patient Care” JAMA, October 14, 2009

  3. Rural General Surgery In a desirable location in Maine, it may take from six months to a year to identify, recruit, and start-up a general surgeon. It less desirable locations it may take two to three years. Maine Recruitment Center

  4. Some Definitions • Some Definitions • What is a rural General Surgeon? • The “old guard” definitions • Scope of Recent Training and Expectations • What Do they do?

  5. Core elements: Adhesions Appendectomy Breast Biopsy Central Line Placements And then you add in bits of: Breast Surgery Colorectal Surgery Surgical Gynecology Vascular Surgery Cholecystectomy Colorectal Procedures Gastric procedures Hernia Repair Endocrine Surgery Surgical Oncology Trauma Surgery Surgical Urology Orthopedics What Do they do?

  6. General Surgery Procedures from Sample of Rural Hospitals

  7. General Surgery Procedures from Sample of Rural Hospitals (Cont.)

  8. One Example of a Regional System Endoscopy 28% Gynecology 21% Hernia 10% Colorectal 9% Biliary Tract 8% Orthopedic 7% Cesarean Section 5% Breast 5% Other 7%

  9. The Major Forces at Play • There has been or is going to be a decline in the number of general surgeons practicing in rural communities. Those who are still practicing are a more rapidly aging cohort. • There is a decline in the number of physicians selecting general surgery as their “specialty” during residency and in the number prepared for or interested in rural practice.

  10. The Major Forces at Play • With these declines, the gap between supply and need is widening. The number of general surgeons “in-the-pipeline” is insufficient to replace those retiring or otherwise leaving rural practices.

  11. Increasing Shortages Are Or Will Be Exacerbated By • Older, sicker, poorer, less insured, rural patients with multiple co-morbidities • Evolving quality expectations of patients, payers, quality advocates— e.g., minimum volume standards and payment policies linked to quality expectations and costs (P4P, Value-based purchasing, Breast Care Centers)

  12. Shortages Are Or Will Be Exacerbated • Malpractice Risks and Insurance Cost • Physicians’ career goals and lifestyle expectations (e.g., clinical interests, income/debt, call coverage, gender effects, isolation) • Difficulties in surgeons accessing continuing education (especially clinical experience)

  13. Shortages Are Or Will Be Exacerbated • Changing practice patterns influenced by technology and physician education • Urban-rural competition • Inadequate reimbursement

  14. Shortages Are Or Will Be Exacerbated • Substitution of mid-level providers for primary care physicians • Increasing costs related to sustaining associated services (technology, facilities, and people)

  15. The Probable Implications for Many CAHs and Other Rural Hospitals • Many hospitals will need to dramatically reduce or cease surgery services associated with an inability to sustain a full-time, or even part-time, general surgery work force.

  16. Probable Implications • Reduced access for patients and their families, compounded by increased travel needs and costs • Deferred care and long-term increases in health care costs • A decrease in health status • Patient migration and erosion of local systems

  17. Probable Implications • In many locations there will be unsustainable hospital operating losses. • Loss of direct surgical revenue (inpatient and outpatient surgery, patients days, endoscopies, ancillary services), indirect revenue associated with other affected programs, and rising costs. • In some cases, this will be the difference between overall hospital profit or loss, success or failure.

  18. Probable Implications • Partial losses of surgical volumes can lead to difficulty in sustaining remaining services. • Operating room nursing staff and anesthesiology support (skills and numbers) • Higher per procedure costs

  19. Probable Implications • Hospital medical staffs and collaboration among medical staffs, boards of trustees, and management teams will be weakened.

  20. Probable Implications • More difficulty sustaining services that are either clinically dependent on surgeons’ availability or subsidized by surgical revenue. • Potential impacts include: • Weakened emergency room and local EMS trauma support, that will in turn increase out-of-area patient transport needs • Declines in obstetrical care (no C-Section back-up, especially for Family Physicians)

  21. Potential impacts continued: • Decreased ability to financially support primary medical care • More difficulty in recruiting and retaining primary care physicians • Declining ability to subsidize programs important to community health

  22. Probable Implications • There will be direct losses of revenues and jobs related to surgery and other hospital services. There will also be extensive secondary effects as these losses ripple through local economies.

  23. A Look at Some of the Economics of Rural Surgery Economic Opportunities Economic Impact

  24. To attract business and industry, research indicates the rural areas need quality: Health services at reasonable costs and Education services

  25. To attract retirees, research indicates the rural areas needs quality: Health services and Safety services

  26. Health Services Promote Job Growth

  27. Economic Opportunity How do you assess your community’s ability to support a general surgeon?

  28. Economic Impacts Direct Impact Secondary Impact

  29. Table 1Estimated Employment and Wage and Salaries in a General Surgeon’s OfficeCaution RHW DRAFT Only Source: MGMA Physician Compensation and Production Survey, MGMA Cost Survey for Specialty Physician: 2008 report based on 2007 data; Local data sampled from rural hospitals.

  30. Table 2 Surgery Procedures, Revenues, Employment and Wage and Salaries at the Hospital Generated by a General Surgeon Caution RHW DRAFT Only Source: Local data sampled from rural hospitals

  31. Table 3Total Impact of Revenue by a General Surgeon Caution RHW DRAFT Only Source: MGMA Physician Compensation and Production Survey, MGMA Cost Survey for Specialty Physician: 2008 Report based on 2007 data; 2007 IMPLAN database, Minnesota IMPLAN Group, Inc.; Local data sampled from rural hospitals.

  32. Table 4Total Impact of a General Surgeon on Income at Surgery Practice and Hospital1 Caution RHW DRAFT Only 1 Income includes wages, salaries and benefits Source: MGMA Physician Compensation and Production Survey, MGMA Cost Survey for Specialty Physician: 2008 Report based on 2007 data; 2007 IMPLAN database, Minnesota IMPLAN Group, Inc.; Local data sampled from rural hospitals.

  33. Table 5Total Impact of a General Surgeon on Employment at Surgery Practice and HospitalCaution RHW DRAFT Only Source: MGMA Physician Compensation and Production Survey, MGMA Cost Survey for Specialty Physician: 2008 Report based on 2007 data; 2007 IMPLAN database, Minnesota IMPLAN Group, Inc.; Local data sampled from rural hospitals.

  34. Table 6General Surgery from Sample of Rural Hospitals Primary Procedures

  35. General Surgery from Sample of Rural Hospitals (Cont.)

  36. Table 7Annual General Surgeon Procedures by Age and Gender1 Caution RHW DRAFT Only DRAFT DO NOT USE • Data based on procedures sampled from rural Hospitals Source: The National Hospital Discharge Survey and National Survey of Ambulatory Surgery, 2006.

  37. Table 8Annual General Surgery Procedures Generated in the Example Medical Service Area1 Caution RHW DRAFT Only DRAFT DO NOT USE • Data based on procedures sampled from rural Hospitals Source: The National Hospital Discharge Survey and National Survey of Ambulatory Surgery.

  38. Table 9Population Ratio for General Surgeon Caution RHW DRAFT Only DRAFT DO NOT USE • Data based on procedures sampled from rural Hospitals 2 Procedures for Non-metro single specialty general surgery practices Source: The National Hospital Discharge Survey and National Survey of Ambulatory Surgery; MGMA Physician Compensation and Production Survey: 2008 report based on 2007 data.

  39. Table 10Another Way of Looking at Need Caution RHW DRAFT Only DRAFT DO NOT USE • Data based on procedures sampled from rural Hospitals Source: The National Hospital Discharge Survey and National Survey of Ambulatory Surgery; MGMA Physician Compensation and Production Survey: 2008 report based on 2007 data.

  40. Probable Implications • General surgery in rural hospitals that requires inpatient stays, and even surgery provided only on an outpatient basis, cannot and should not be sustained in all current locations… despite the serious implications of service declines.

  41. Possible Strategies to Mitigate a Crisis • To solve a problem, one must first understand the problem William Osler • Without greater understanding of the forces at play, analysis of the implications, identification of steps to mitigate negative impacts, and purposeful intervention there will be continued movement toward a crisis without solutions. • Increase Collaborative Problem Solving

  42. Possible Strategies to Mitigate a Crisis • Some Specific Ideas • Improve Reimbursement • Improve Continuing Education • Reduce Isolation • Develop Rural-Relevant Residencies (Scope and locations) and couple with Economic Incentives (debt relief and reimbursement improvement) • Expand use of NHSC • Revise Definitions of MUAs and HPSAs • Increase the Use of FMGs • Expand Supportive Technologies • Develop New Regional Models (and expanded existing ones that work)

  43. Conclusions • The future of general surgery in the nation’s rural hospitals is muddled. However, the direction in which many physicians, hospitals, and communities are moving is clear; many are moving toward significant problems.

  44. Contact Information Jonathan Sprague, President Rocky Coast Consulting PO Box 1131 Bangor, Maine 04402-1131 2078-990-0880 JonathanSprague@RockyCoastConsulting.com Gerald Doeksen, PhD, Director Center for Rural Health Works 508 Agricultural Hall Oklahoma State Stillwater, Oklahoma 74078-6026 (405) 744-6083 gad@okstate.edu Visit the Center for Rural Health Works at www.ruralhealthworks.org

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