State Patterns in Medical School Expansion : Variation, Discord and Policy Priorities Benjamin Adler, MS II Wendy Biggs, MD Andrew Bazemore, MD

Disclosures Benjamin Adler – nothing to disclose Dr. Biggs – nothing to disclose Dr. Bazemore – nothing to disclose

Medical School Capacity: today Surplus to Shortage GMENAC(1980) – Surplus; expansion stops COGME & AAMC ( ): Looming shortage; recommends15-30% increase in allopathic medical school enrollment by 2016

Expansion present Allopathic schools respond –Increased class sizes –Added regional medical campuses –Created new medical schools Osteopathic/Offshore expansion was already underway

Hypotheses Did medical school expansion correspond to increase in states’ populations from ? How did increases in active primary care physicians per capita relate to medical students per capita and medical school retention (students returning to state of med school training?

Methods Population data – 2000 and 2010 US Census AAMC 2011 State Physician Workforce Data Book –# of MD and DO students in 2000 and 2010 –# of active primary care physicians

Methods Med School Mapper (medschoolmapper.org) –State medical student retention rates –Used 2009 AMA Physician Masterfile data WWAMI –Provided medical student admission data

New medical schools By 2013 – LCME listed 15 new medical schools in process Jan 2014 – Now applicant, 5 provisional, 7 preliminary accreditation New DO schools – 17 since 2003 (including new branch campuses)

Results Median state population growth = 7.4% Median medical school enrollment = 14.7% Retention rates – range from 10%-67% Wide range of concordance and discordance

Population vs medical school enrollment

Concordance StateMedical School enrollment growth Population growth Nevada273.7%35.2% Arizona116.9%24.6% Kansas2.8%6.1% Maine9.7%4.2% Iowa0.9%4.1% Missouri11.2%7.0% Nebraska8.8%6.7% Alaska96.6%13.3% Georgia48.4%18.3% NOTE: Green values are above and Red values are below the national median for states

Discordance StateMedical School enrollment growth Population growth West Virginia80.0%2.5% Michigan37.3%-0.6% Utah-2.9%23.8% New Hampshire27.2%6.5% Vermont24.4%2.8% Mississippi49.8%4.3% Alabama10.2%7.5% Arkansas11.6%9.1% NOTE: Green values are above and Red values are below the national median for states

Retention rates vs medical school enrollment

Concordance StateMedical School enrollment growth Retention rate ( returning to state of medical school education) Arizona116.9%47.2% Kansas2.8%37.1% Maine9.7%16.9% Iowa0.9%22.7% Missouri11.2%21.6% Nebraska8.8%25.8% Alaska96.6%51.0% Mississippi49.8%55.0% Georgia48.4%48.0% NOTE: Green values are above and Red values are below the national median for states

Discordance StateMedical School enrollment growth Retention rate (returning to state of medical school education) West Virginia80.0%33.9% Michigan37.3%45.3% Utah-2.9%46.1% New Hampshire27.2%9.8% Vermont24.4%12.9% Nevada273.7%40.8% Alabama10.2%52.4% Arkansas11.6%59.1% NOTE: Green values are above and Red values are below the national median for states

Primary care “supply” What is a state’s primary care physician supply compared to the number of medical students in the state in 2010?

High Supply PCPs, High number of medical students Low Supply PCPs, Higher number of medical students High Supply PCPs, Low number of medical students Low Supply PCPs, Low number of medical students

Physician Production and Primary Care Supply State2010 medical school enrollment per 10,000 people 2010 active patient care primary care physicians per 10,000 people Category Michigan High Production, High Supply New York High Production, High Supply Missouri High Production, Low Supply Nebraska High Production, Low Supply Hawaii Low Production, High Supply Oregon Low Production, High Supply Florida Low Production, Low Supply Utah Low Production, Low Supply NOTE: “High” and “Low” is relative to the national median for states

Results Free market expansion – very variable in states DO school enrollment triples from 2002 to 2016 to reach >7200 students/year Combined MD and DO student enrollment increased >37% since 2002

Is medical education truly a national market? 63% of medical students enter medical school in state of residence Only 39% of MDs and DOs return to practice in state where they went to medical school 56% of FM residents practice within 100 miles of their residency site. (Fagan et al, Nov 2013)

Conclusions Retention rate data important for state stakeholders States with low retention rate and state-funded medical education may need policy or legislation changes Supply of PCPs Low primary care in state Need policy or legislation to encourage medical student selection of family medicine

Medical Schools Social Mission Score, Primary Care, HPSA and Minorities RankSchool NameState Social Mission Score % Primary Care [std score] % HPSA URM School State (Nation) Ratio School URM % State (Nation) URM % [std score] 1MorehouseGA [1.20]39.1[1.40]3.15[11.38]83.3%26.5% 2MeharryTN [2.00]28.1[0.14]2.99[10.78]79.3%26.5% 3HowardDC [0.19]33.7[0.78]2.71[9.68]71.9%26.5% 4 Wright State- BoonshoftOH [1.98]28[0.12]1.31[3.23]19.0%14.5% 5U KansasKS [1.42]43.9[1.96]0.77[1.12]11.6%15.1% 6 Michigan State UniversityMI [1.20]26.5[-0.05]1.24[2.99]23.7%19.1% 7East Carolina-BrodyNC [2.36]34.2[0.84]0.62[0.52]17.3%28.1% 8U South AlabamaAL3.1542[0.97]52.7[2.97]0.29[-0.78]8.2%28.7% 9PoncePR3.0233[-0.31]43.8[1.94]0.84[1.38]82.5%26.5% 10Iowa-CarverIA [0.28]21[-0.69]1.35[3.38]8.1%6.0%

Medical Schools Social Mission Score, Primary Care, HPSA and Minorities RankSc hool NameState Social Mission Score % Primary Care [std score] % HPSA URM School:State (Nation) Ratio School URM % State (Nation) URM % [std score] 132EinsteinNY [-1.28]24.8[-0.25]0.33[-0.60]8.8%26.5% 133Stony BrookNY [-0.85]20.4[-0.76]0.33[-0.60]10.5%31.7% 134JeffersonPA [-0.42]20.6[-0.72]0.18[-1.19]4.8%26.5% 135Uniformed ServicesMD [-0.78]21.4[-0.64].024[-0.95]6.5%26.5% 136UMDNJ-New JerseyNJ [-1.61]17.8[-1.05]0.54[0.20]14.8%27.7% 137New York UniversityNY [-1.53]22.1[-0.55]0.34[-0.57]9.0%26.5% 138UC IrvineCA [-0.32]14.2[-1.47]0.17[-1.24]7.0%41.2% 139 Northwestern- FeinbergIL [-1.51]19.5[-0.86]0.30[-0.74]7.9%26.5% 140UT SouthwesternTX [-1.18]15.1[-1.36]0.21[-1.09]9.3%44.7% 141VanderbiltTN [-1.86]20.8[-0.70]0.13[-1.38]3.6%26.5%

Social Mission Drivers School mission statement Pipeline cultivation Student admissions Structure and content of curriculum Location of clinical experience Tuition management Mentoring and role modeling Preparation for residency

Conclusions Branch campus effect –Medical students educated on branch campuses more likely to enter primary care More states may want to consider WWAMI model

Conclusions GME bottleneck –Without increase in GME positions, US grads will not match –US grads will just squeeze out international graduates Coordination of GME expansion imperative!

Academic Medicine December 2013