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Maryland Physician Workforce Study Rural Health Roundtable October 2, 2008 Robert A. Barish, M.D. Vice Dean, Clinical Affairs Professor , Emergency Medicine and Medicine University of Maryland School of Medicine *Robert A. Barish , M.D., Chair

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rural health roundtable october 2 2008

Maryland Physician Workforce Study

Rural Health RoundtableOctober 2, 2008

Robert A. Barish, M.D.Vice Dean, Clinical AffairsProfessor, Emergency Medicine and Medicine

University of Maryland School of Medicine

maryland physician workforce study steering committee
*Robert A. Barish, M.D., Chair

Vice 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, CFO

Johns Hopkins Medicine

Scott Hagaman, M.D.

President, MedChi

*Harry C. Knipp, M.D., Chair

Maryland Board of Physicians

Scott E. Maizel, M.D.

Surgery Representative

Stephen J. Rockower, M.D.

Medical Specialty Representative

Joseph Twanmoh, M.D.,FACEP

Vice President, American College of

Emergency Physicians, MD Chapter

Joseph W. Zebley, III, M.D., FAAFP

PrimaryCare Representative

Maryland Physician Workforce StudySteering Committee

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

slide11

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
slide13

Medical Specialty

  • Allergy
  • Cardiology
  • Dermatology
  • Endocrinology
  • Gastroenterology
  • Hematology/Oncology
  • Infectious Disease
  • Nephrology
  • Neurology
  • Psychiatry
  • Pulmonary Medicine
  • Rheumatology
  • Primary Care
  • Family Medicine
  • Geriatric Medicine
  • Internal Medicine
  • Pediatrics
slide14

Surgical Specialty

  • General Surgery
  • Neurosurgery
  • OB/GYN
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Plastic Surgery
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
  • Hospital-Based
  • Anesthesiology
  • Diagnostic Radiology
  • Emergency Medicine
  • Neonatology
  • Pathology
  • Physical Medicine
  • Radiation Oncology
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-renewals

1,716

Step 1: Calculation of Baseline Practicing Physician Supply

Currently Licensed

Physician Supply

24,968

Adjusted Baseline

Physician Supply

14,891

MINUS

EQUALS

Source: Maryland Board of Physicians

step 2 calculation of 2007 clinical physician supply

Adjusted Baseline

Physician

Supply

14,891

Total Clinical Physician

Supply

10,227

Adjusted by

FT/PT Status

Step 2: Calculation of 2007 Clinical Physician Supply

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.

Adjusted by %

Clinical Status

step 4 forecast physician supply for 2010 2015
Step 4: Forecast Physician Supply for 2010 & 2015

Retirements/

Deaths

Net

In-Migration

Forecasted

Clinical

Physician

Supply

2010 & 2015

Clinical

Physician

Supply

2007

MINUS

PLUS

EQUALS

Gender/

Lifestyle

Residents

Remaining

In MD

step 5 calculate impact of residents in graduate medical education programs
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
total clinical physicians per 100 000 residents by region compared to state and national levels
Total Clinical Physicians per 100,000 Residents by Region Compared to State and National Levels

US

MD

percentage of medical specialists age 60 and older by region 2007
Percentage of Medical Specialists Age 60 and Older by Region2007
  • Medical Specialties significantly impacted by retirements (age of the workforce)
  • Capital and Eastern regions have highest percentage of physicians over Age 60
overall observations regarding primary care requirements versus supply
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
overall observations regarding medical specialty requirements versus supply
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
overall observations regarding surgical physician requirements versus supply
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 addressboth competitive compensation & on call needs
future vs historical trends
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.

maryland physician workforce study current physician shortages by region 2007

Legend

Adequate

Physician

Supply

Borderline Physician

Supply

Physician

Shortage

Maryland Physician Workforce Study – Current Physician Shortages by Region2007

*Physician Only **Physician & Resident Model

maryland physician workforce study current physician shortages by region 2015

Legend

Adequate

Physician

Supply

Borderline Physician

Supply

Physician

Shortage

Maryland Physician Workforce Study – Current Physician Shortages by Region2015

*Physician Only **Physician & Resident Model

summary of findings28
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

major conclusions maryland has a growing physician crisis
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.
major conclusions
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.
major conclusions32
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.
major conclusions33
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.
major conclusions34
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.
slide35

POLICY RECOMMENDATIONS

Recruitment and Retention: Reimbursement

  • 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.
slide36

POLICY RECOMMENDATIONS

Recruitment 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
policy recommendations
POLICY RECOMMENDATIONS

Retention of Maryland Residents in Training

  • 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.
policy recommendations38
POLICY RECOMMENDATIONS

Retention of Maryland Residents (Cont’d.)

  • 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.
policy recommendations39
POLICY RECOMMENDATIONS
  • Increase the number of residency slots.

Retention of Maryland Residents (Cont’d.)