Primary Care Physician Scan in Georgia: 2014 RECRUITMENT, RETENTION, AND COORDINATION

Physician To Population Ratio The state ranked 39th in the ratio of doctors per 100,000 population in 2010, the latest year for which data are available. That’s a slight improvement from Georgia’s 40th-place ranking in 2008.

Georgia’s Medical Workforce: Geographic 159 Counties: ◦6 without a Family Physician ◦31 without a General Internist ◦63 without a Pediatrician ◦79 without an OB/GYN ◦66 without a General Surgeon ◦Source: GBPW, 2014

Snapshot of Georgia: Race (Source: GBPW, 2007)

Snapshot of Georgia: Gender (Source: GBPW, 2007)

To make a physician… The physician education pipeline is quite long ◦(K-12 education) ◦4 years of undergraduate education ◦4 years of medical school ◦3-8 years of residency training YEARS POST HIGH SCHOOL TO EDUCATE A NEW DOC!

PHASES OF MEDICAL EDUCATION

AHEC roles across the Pipeline: Phases 1 and 2 PREMATRICULATION: K-12; UNDERGRADUATE/BACCALAUREATE YEARS FOCUS: Recruitment and exposure of youth to variety of health careers available and the requirements to pursue each one; working with high school and college counselors to equip them with knowledge and resources to effectively advise students. STRATEGIES: ◦General Classroom presentations ◦Intensive health career camps and programs (20+ hours) ◦Shadowing opportunities ◦Counseling 1:1 ◦Publication and dissemination of the Health Careers Manual ◦Production of Health Career videos for classroom use SUMMARIZED OUTCOMES (FY 14): Exposed 27,558 youth to health career opportunities through 755 regional AHEC activities and programs Supported 1,069 students in intensive health career programs

Do we have enough physicians in the pipeline to meet our need?- Factors to consider o Impact of ACA o Number and training of medical school graduates in Georgia o GME programs in Georgia o -the “lowest hanging fruit” results from changes in Phases 3 and 4

Impact of the ACA

The Effects of Expanding Primary Care Access for the Uninsured: Implications for Health Workforce under Health Reform Academic Medicine, Vol. 88, No. 12/ December 2013 “Meeting the workforce demands of the newly insured under new coverage programs… may require new processes of care, realignment of patient and providers, changes in the roles of physicians and other providers, and modifications to how health care providers are trained and care is led.” Older students, female students, and students from minority backgrounds are more likely to enter PC and / or to practice in underserved areas Students with rural backgrounds are more likely to practice in rural areas

Challenges and Opportunities in Building a Sustainable Rural Primary Care Workforce in Alignment with the Affordable Care Act Academic Medicine, Vol. 88, No. 12/ December 2013 “With expanded health care access for patients, primary care physicians, PA’s and NP’s will be in even greater demand than in the past. “

HRSA: Projected Demand for Primary Care Physicians Total primary care physician demand (FTE) 212,500 a 241,200 General b 164,400187,300 Pediatrics44,80049,600 Geriatrics3,3004,300 Primary care physician supply205,000220,800 Supply and demand (7,500)(20,400) a National demand projections presented in this report assume that in 2010 the national supply of primary care physicians was adequate except for the approximately 7,500 FTEs needed to de-designate the primary care HPSAs. b This category includes general and family practice, and general internal medicine.

NACHC Access 2015: Georgia Goals Georgia Medically Disenfranchised = 1,335,787 Access 2015 Goal (25%) = 333,947 CHC patients 2006 = 248,205 Anticipated CHC patients 2015 = 582,152

How many Primary Care providers will we need? To cover CHC increase Need 88 new PA / NP Need 168 new Primary Care Physicians To cover all 1,335,787 Need 351 new PA/NP Need 676 new Primary Care Physicians Access Transformed -Building a Primary care Workforce for the 21st Century; NACHC, Robert Graham Center, George Washington University School, 2010

o Number and training of medical school graduates in Georgia

Number and training of medical school graduates in Georgia

Quick Scan of Key Measures Medical Student Debt and Primary Care Income

Medical Schools in Georgia: 2014 SCHOOLANNUAL TUITIONESTIMATED # OF STUDENTS ( ) TOTAL TUITION COSTS EMORY45, ,310,000 MCG24, ,066,552 MERCER41, ,043,859 MOREHOUSE36, ,487,690 GA-PCOM40, ,916,680 TOTAL2377$84,824,781

Bottleneck: Community Based Training Sites to support core clerkships MEDICAL STUDENTS: Each medical student has approximately 7 required core clerkship rotations in their third year. (Family Medicine, Internal Medicine, Pediatrics, Emergency Medicine, OB/GYN, Psychiatry, and General Surgery) ◦Each rotation lasts 4-6 weeks on average. ◦Approximately 40% of these required clerkship rotations occur in community based settings with non- compensated volunteer faculty; ◦In 2012, there were approximately rd year Georgia Medical Students at our five schools ◦594 x 7 required core clerkships = 4,158 rotations; ◦4,158 x 40% in community settings = 1,663 rotations in uncompensated community sites ◦In 2020 it is estimated that Georgia will have rd year medical students needing +/-3,212 off campus community based training with a CBF member.

AHEC roles across the Pipeline: Phase 3 MEDICAL SCHOOL YEARS FOCUS: Support student rotations in community based settings remote from home campus, to expose students to rural areas and AHEC regions and to develop relationships with students for eventual recruitment into the host regions. STRATEGIES: ◦Locate / partner with appropriate community based training sites and assist with academic credentialing of providers to become community based faculty ◦Provide preceptor faculty development programs and trainings ◦Provide Housing for students on rotations remote from their campus ◦Provide travel assistance to students on rotations remote from their campuses ◦Manage the flow of students into practices to prevent chaos SUMMARIZED OUTCOMES (FY 14): Worked with 1,257 community based faculty clinical preceptors Supported travel and housing for 2,573 health profession student rotations Worked with 2,803 health professions students in 4,153 rotations in clinical training sites for a total of 656,072 training hours Implementing PTIP

Driving forces against PC choices by medical students 1. Primary Care physicians continue to make approximately 50% of what a specialist makes even though their debt load is the same. 2.The interest accrued from Government student loans generated $66 billion between (recently released report from the GAO, 2014) 3.Current medical student loans are provided with interest rates of approximately 6.8%-7.9%. 4.The average medical student debt is $170,000; according to the AAMC a doctor owing $175,000 at graduation can end up repaying more than $300,000 once interest is factored in.

National Medical Student Debt (NEJM, 2008) * Estimated at $145,000 for public and $180,000 for private medical school graduates *Total medical student debt estimated at $2 billion per year *The federal “cash for clunkers” program cost $2 billion per month *If medical school tuition was made free, it would cost approximately $2.5 billion per year ◦( Bach and Kocher, New York Times article, 5/28/11)

Can Medical Students Afford to Choose Primary Care? (Academic Medicine, January 2013) “Graduates pursuing primary care with higher debt levels ($250,000-$300,000) need to consider additional strategies to support repayment… use of federal loan forgiveness…”

 Students entering now will graduate over $250,000 in debt.  In Georgia, tuition increases in last 5 years:  Emory $34,205 to $42, %  MCG $10,772 to $21, %  Mercer $27,876 to $39, %  Morehouse $22,500 to $29, %  PCOM $38,100 DEBT DISCOURAGES PRIMARY CARE GME

Potential Strategies: Phase 3 Reduction of interest rates on medical school debt Reduction in tuition costs Full/ partial loan repayment / start in residency years for PC Free medical school tuition for primary care Free medical school tuition for all

GME programs in Georgia

Quick Scan of Key Measures Update on GME in Georgia, courtesy of the Georgia Board for Physician Workforce, April 2014 report

Off Shore Medical Graduates and GME: Selected Facts and Figures ◦Data is sketchy at best, but we do know that IMG are contributing to the physician workforce in the US and in Georgia. ◦According to the office of Senator Richard Durbin (Illinois), Caribbean Medical Schools received over $450 million in US Department of Education Title IV funding in ◦Texas, during the 2013 Legislative session, passed a law barring foreign medical schools from buying up core clinical training spots at Texas teaching hospitals and institutions. ◦IMGs constitute approximately 25% of the US physician workforce and approximately 29% of US physician residency training program slots. ◦IMGs are required to complete residency training in the US and most enter the country on J-1 visas whose holders are required to leave the US for 2 years before they return. The exception is under the Conrad J-1 visa waiver which allows state health departments to request 30 visa waivers annually for IMGs working for approved employers. ◦31.3% of Georgia GME graduates in 2013 attended medical school in another country.

Growing Imbalance of Med Ed System ◦UME expansion is occurring at nearly double the rate of GME ◦Georgia ranks 39th ◦Georgia ranks 39th in total residents per capita ◦GA rate is 20.8/100,000; National rate is 35.7/100,000 ◦Per capita growth in GME capacity has been minor in last 10 years 1,450 ◦Georgia needs 1,450 more positions to match the US average (or 315 to meet SE average) Bottom Line: The lack of GME positions is forcing students out of state to complete training, decreasing the likelihood that they will practice in Georgia Source: Graduate Medical Education Data Resource Book; ACGME,2010

Origins of GME Crisis in Georgia Medicare GME Capped (12/31/96 -BBA 1997) Georgia grew M +77% USA grew M +36% New England has all states with > 50 residents/100,000 Georgia is capped at 20.8 residents/100,000 New England 350 Physician/100,000 Georgia 200 Physician/100,000

GME and GME Graduates Data Brief, March 2013, Georgia Board Physician Workforce, 2012 Key Findings: 50.0% of GA GME graduates are remaining in Georgia to practice Existing GME programs in GA have experienced a 17.6% decrease in state funding since 2009 In 10 years, the percent of graduates with debt over $200,000 has increased from 3% to 30% The average starting salary of respondents entering primary care was $168,280; the average for all other specialties was $231,318 Average starting salary for pediatrics was $135,125 Average starting salary for cardiovascular surgeons was $321,000

SO WHAT DO WE NEED TO DO? CONFRONTING GEORGIA’S HEALTH WORKFORCE SHORTAGES

STRATEGIES AND OPPORTUNITIES  Remove or adjust the GME caps imposed by the Balanced Budget Act  Immediately open new GME slots in areas of population growth  Increase federal and state loan repayment programs for PC residents and graduates  Increase # of PC residency slots  Protect existing residency programs from funding cuts and recognize the number of unfunded (over the cap) slots programs are supporting  Address payment differentials immediately  Implement rural / primary care admissions tracks and curriculum at our medical schools

2014 GAINS

Increase the number of GME Loan Forgiveness Awards AND the amount of each award, as administered by the Georgia Board for Physician Workforce. STATUS: The GBPW budget was increased to provide 10 additional GME Loan Forgiveness Awards at the $20,000/year level. While the awards were not increased to the $30,000 level requested, the new funds do provide for an increase from 16 to 26 awards.

Support the Board of Regents request for $3,225,000 in new funds to support creation of new residency slots in Georgia STATUS: The Conference Committee elected to provide $2,000,000 for this initiative in FY 2015.

Support the Georgia Board for Physician Workforce proposal to increase primary care residency capitation funds by $3,489,440 for new and expansion positions in the FY 15 budget STATUS: Increase all Georgia Board for Physician Workforce capitation residency grants by $333 in state funds ($498,168); most of these will qualify for federal match.

Revising the powers of the GBPW as it relates to medical student scholarships STATUS: HB 998 passed which revises the powers of the Georgia Board for Physician Workforce as it relates to medical student scholarships. This provides expanded latitude for the GBPW to establish population and specialty rules based on the needs of the state without seeking legislative changes.

Increasing housing resources for AHEC The 2014 Legislature provided an additional $300,000 for FY 15 to the Statewide AHEC Network to support housing to support community based clinical training. This has already resulted in an increase of housing sites and housing beds within these sites. FY 2014FY 2015% CHANGE NUMBER OF COUNTIES % NUMBER OF BEDS %

Provide tax deductions for community based faculty precepting 3 rd and 4 th year Georgia medical students (SB 391) SB 391 was passed creating the first community based faculty tax deduction in the country. Off-shore and out-of-state medical schools are using Georgia CBF and paying them +/-$1500 per rotation. Rather than engaging in a bidding war, the tax deduction is a proactive strategy to provide a powerful incentive to Georgia CBF to take Georgia Medical, Physician Assistant, and Nurse Practitioner students.

PTIP UPDATE

Eligible Programs: Physician Emory University School of Medicine Medical College of Georgia (Georgia Regents University) Mercer University School of Medicine Morehouse School of Medicine Philadelphia College of Osteopathic Medicine, Georgia Campus

Eligible Programs: Physician Assistant Emory University PA Program Georgia Regents University PA Program Mercer University PA Program South University PA Program PCOM-GA Campus PA Program

Eligible Programs: Nurse Practitioner Albany State University Armstrong Atlantic University Brenau University Emory University Georgia College and State University Georgia Regents University Georgia Southern University Georgia State University Kennesaw State University Mercer University University of North Georgia Valdosta State University

Certification The Statewide Area Health Education Centers Program Office at Georgia Regents University shall administer the program and certify rotations for the department. Individual academic programs will report completed qualifying rotations to the Statewide AHEC Program Office

GA-PTIP Website: Will be live by mid-September Will feature two online reporting portals: ◦Physician Registration ◦Program Reporting Will provide FAQs, Eligibility Guidelines, Training Opportunities, Program Guidelines, News and Updates

Statewide AHEC Program Office *Will maintain website and portals *Data will be summarized at the Statewide AHEC Program Office *Tax Deduction Certification letters will be issued by the Program Office in January of each year for the last full calendar year *Provide a report to the Legislature each year

CONTACT ME DENISE D. KORNEGAY, MSW Associate Dean, Area Health Education Centers Associate Professor, Department Of Family Medicine Medical College Of Georgia Georgia Regents University