1. Rural Medicine in the 21 st Century October 30, 2010 Rural Medicine in the 21 st Century Family Medicine Innovations: Blueprints For Health System Redesign October 30, 2010 Fiona M c Lellan, MD, FAAFP Assistant Director Altoona Family Physicians fmclellan@altoonafp.org

2. Objectives: To understand the future shortage of physicians in the US To understand the future shortage of physicians in the US To understand the importance of primary care physicians in providing healthcare in rural areas To understand the importance of primary care physicians in providing healthcare in rural areas To understand the major challenges that face rural primary care physicians today To understand the major challenges that face rural primary care physicians today To discuss specific issues unique to rural practice To discuss specific issues unique to rural practice To provide some inspiration for your future To provide some inspiration for your future

3. US Healthcare Today: 2009 AMA data/www.bls.gov 2009 AMA data/www.bls.gov –661 400 physicians and surgeons –40% in primary care fields 12.4% Family Practice 12.4% Family Practice 20.1% Internal Medicine 20.1% Internal Medicine 9.6% Pediatrics 9.6% Pediatrics 5.6% Obstetrics and Gynecology 5.6% Obstetrics and Gynecology –60% specialty areas 5% anesthesiology 5% anesthesiology

4. Good news! Employment of physicians and surgeons expected to grow 22% from 2008 to 2018 Employment of physicians and surgeons expected to grow 22% from 2008 to 2018 Projected to need 805 500 physicians and surgeons by 2018 Projected to need 805 500 physicians and surgeons by 2018 144 100 more doctors needed 144 100 more doctors needed 16 000 US med school graduates/year 16 000 US med school graduates/year 22 800 residency positions available 2010 22 800 residency positions available 2010

5. Factors Affecting Physician Shortage 1)baby boomer retirement 1)baby boomer retirement 2)women in medicine 2)women in medicine 3)malpractice cost 3)malpractice cost 4) rising practice costs 4) rising practice costs 5)HMOs 5)HMOs

6. Factors Affecting Physician Shortage 6)Medicare and Medicaid 6)Medicare and Medicaid 7)Alternative employment 7)Alternative employment 8)Work week 8)Work week 9)Universal health care 9)Universal health care Russell Coile, Jr Physician Executive 2003 Russell Coile, Jr Physician Executive 2003

7. Shortage of Primary Care Providers 50.7 million currently uninsured 50.7 million currently uninsured –Impact of federal health bill –Deficit of PCPs >30 000 needed Baby boomer retirement Baby boomer retirement 98% IM residents plan sub-specialty careers 98% IM residents plan sub-specialty careers Census Bureau Data Sept 2010

8. Access to Care in Rural America 1548 rural US counties, not PCHPSAs 1548 rural US counties, not PCHPSAs 68% would become PCHP shortage areas if Family Physicians removed 68% would become PCHP shortage areas if Family Physicians removed Visits to physicians per year 902 million Visits to physicians per year 902 million 198 million to Family Physicians 198 million to Family Physicians Family Physicians comprise only 20% of outpatient physician workforce Family Physicians comprise only 20% of outpatient physician workforce Only 9% physicians work in rural settings Only 9% physicians work in rural settings Robert Graham Center for Policy Studies in Family Practice and Primary Care www.cdc.gov

9. Challenges for Rural Medicine - 1 Higher morbidity and mortality rates Higher morbidity and mortality rates –MVA death rate is higher due to fewer trauma centers –Higher infant mortality rates –Higher chronic disease rates Resources Resources –Confidence level managing vast range of problems remote from tertiary care centers –Medicare reimbursement calculations favor tertiary care centers Equipment Equipment –Lack of extensive lab, imaging, blood banks

10. Challenges for Rural Medicine - 2 Personnel Personnel –Lack of job opportunities for spouses –Sufficient work load to justify viable group size –Confidentiality –Lack of trained ancillary personnel –Scarcity of dentists, psychologists, physical therapists Poverty Poverty –11% urban patients –14% rural patients

11. Challenges for Rural Medicine – 3 Transportation Transportation –Costs of emergency transportation doubled –Patients frequently have no vehicle –Patients cannot afford to go to tertiary care centers/specialists Communications Communications –Improved 911 systems Technology Technology –EMR –Internet access –Telemedicine

12. Issues Unique to Rural Practice Location Location –75% physicians practice in urban settings –25% in non-metro areas including suburban –9% in true rural areas - serve 17% US population covering 80% of US land mass –3% current med students plan to practice in rural area Access to specialists/treatment Access to specialists/treatment –OB providers –NICU/PICU –Rural General Surgeons –Dialysis Urgent/emergent care providers Urgent/emergent care providers

13. Benefits of Rural Practice Lower cost of living Lower cost of living Great physician-patient relationships Great physician-patient relationships Close-knit medical community Close-knit medical community No traffic/parking issues No traffic/parking issues Short commute Short commute Close proximity to recreation areas Close proximity to recreation areas Broader scope of practice Broader scope of practice

14. Incentives for you! Guaranteed employment Guaranteed employment High earning potential High earning potential High quality of life High quality of life Loan repayment Loan repayment –Currently $114,000 if stay in PA shortage area as Primary Care Physician –$145, 000 National Health Service Corps Program

15. Rural Medicine – The Future Telemedicine Telemedicine –Liability –Reimbursement Home Visits Home Visits Mid-level providers Mid-level providers Quality assurance Quality assurance PCMH PCMH Increasing primary care training positions Increasing primary care training positions Attracting and retaining more rural physicians Attracting and retaining more rural physicians

16. Recommended reading Textbook of Rural Medicine: Eds John Geyman, Thomas Norris and L. Gary Hart, McGraw-Hill 2001 Textbook of Rural Medicine: Eds John Geyman, Thomas Norris and L. Gary Hart, McGraw-Hill 2001 Critical Issues In Rural Health: Eds Lois Wright, Nan E. Johnson, Nina Glasgow, Wiley-Blackwell 2004 Critical Issues In Rural Health: Eds Lois Wright, Nan E. Johnson, Nina Glasgow, Wiley-Blackwell 2004 Bryson City Tales by Walter Larimore, Zondervan 2002 Bryson City Tales by Walter Larimore, Zondervan 2002

17. Questions?