1. State Patterns in Medical School Expansion 2000-2010: Variation, Discord and Policy Priorities Benjamin Adler, MS II Wendy Biggs, MD Andrew Bazemore, MD

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

3. Medical School Capacity: 1980- today Surplus to Shortage GMENAC(1980) – Surplus; expansion stops COGME & AAMC (2005-06): Looming shortage; recommends15-30% increase in allopathic medical school enrollment by 2016

4. Expansion 2005 - present Allopathic schools respond –Increased class sizes –Added regional medical campuses –Created new medical schools Osteopathic/Offshore expansion was already underway

5. Hypotheses Did medical school expansion correspond to increase in states’ populations from 2000- 2010? 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?

6. 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

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

8. New medical schools By 2013 – LCME listed 15 new medical schools in process Jan 2014 – Now 16 - 4 applicant, 5 provisional, 7 preliminary accreditation New DO schools – 17 since 2003 (including new branch campuses)

9. 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

10. Population 2000-2010 vs medical school enrollment

11. Concordance StateMedical School enrollment growth 2000-2010 Population growth 2000-2010 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

12. Discordance StateMedical School enrollment growth 2000-2010 Population growth 2000-2010 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

13. Retention rates vs medical school enrollment

14. Concordance StateMedical School enrollment growth 2000-2010 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

15. Discordance StateMedical School enrollment growth 2000-2010 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

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

17. 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

18. 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 Michigan3.858.59High Production, High Supply New York4.999.28High Production, High Supply Missouri6.407.42High Production, Low Supply Nebraska5.687.42High Production, Low Supply Hawaii1.889.98Low Production, High Supply Oregon1.359.37Low Production, High Supply Florida2.157.76Low Production, Low Supply Utah1.445.98Low Production, Low Supply NOTE: “High” and “Low” is relative to the national median for states

19. 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

20. 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)

21. 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

23. 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] 1MorehouseGA13.9843.7[1.20]39.1[1.40]3.15[11.38]83.3%26.5% 2MeharryTN12.9249.3[2.00]28.1[0.14]2.99[10.78]79.3%26.5% 3HowardDC10.6636.5[0.19]33.7[0.78]2.71[9.68]71.9%26.5% 4 Wright State- BoonshoftOH5.3449.2[1.98]28[0.12]1.31[3.23]19.0%14.5% 5U KansasKS4.4945.2[1.42]43.9[1.96]0.77[1.12]11.6%15.1% 6 Michigan State UniversityMI4.1343.6[1.20]26.5[-0.05]1.24[2.99]23.7%19.1% 7East Carolina-BrodyNC3.7251.9[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-CarverIA2.9737.1[0.28]21[-0.69]1.35[3.38]8.1%6.0%

24. 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-2.1326.1[-1.28]24.8[-0.25]0.33[-0.60]8.8%26.5% 133Stony BrookNY-2.2129.1[-0.85]20.4[-0.76]0.33[-0.60]10.5%31.7% 134JeffersonPA-2.3432.1[-0.42]20.6[-0.72]0.18[-1.19]4.8%26.5% 135Uniformed ServicesMD-2.3629.6[-0.78]21.4[-0.64].024[-0.95]6.5%26.5% 136UMDNJ-New JerseyNJ-2.4623.7[-1.61]17.8[-1.05]0.54[0.20]14.8%27.7% 137New York UniversityNY-2.6524.3[-1.53]22.1[-0.55]0.34[-0.57]9.0%26.5% 138UC IrvineCA-3.0232.9[-0.32]14.2[-1.47]0.17[-1.24]7.0%41.2% 139 Northwestern- FeinbergIL-3.1124.4[-1.51]19.5[-0.86]0.30[-0.74]7.9%26.5% 140UT SouthwesternTX-3.6426.8[-1.18]15.1[-1.36]0.21[-1.09]9.3%44.7% 141VanderbiltTN-3.9521.9[-1.86]20.8[-0.70]0.13[-1.38]3.6%26.5%

25. 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

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

27. 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!

28. Academic Medicine December 2013