1. 1 October 2, 2008 Rural Health Roundtable October 2, 2008 Robert A. Barish, M.D. Vice Dean, Clinical Affairs, Emergency Medicine and Medicine Robert A. Barish, M.D. Vice Dean, Clinical Affairs Professor, Emergency Medicine and Medicine University of Maryland School of Medicine Maryland Physician Workforce Study

2. 2 National Issue The United States will face a serious doctor shortage in the next few decades. Our nation’s rapidly growing population, increasing numbers of elderly Americans, and aging physician workforce, and a rising demand for health care services all point to this conclusion. Source: AAMC

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11. 11 Goals of the Study  Document current and future shortages by region and specialty  Determine impact on access  Document key physician environment issues and potential impact on supply  Engage physicians and hospitals in the discussion and develop consensus for solutions

12. 12 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 Primary Care Representative *State agency representatives participated on the Steering Committee to assist the effort without taking a position on its policy recommendations.

13. 13 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

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15. 15 Primary Care  Family Medicine  Geriatric Medicine  Internal Medicine  Pediatrics Medical Specialty  Allergy  Cardiology  Dermatology  Endocrinology  Gastroenterology  Hematology/Oncology  Infectious Disease  Nephrology  Neurology  Psychiatry  Pulmonary Medicine Rheumatology

16. 16 Hospital-Based  Anesthesiology  Diagnostic Radiology  Emergency Medicine  Neonatology  Pathology  Physical Medicine  Radiation Oncology Surgical Specialty  General Surgery  Neurosurgery  OB/GYN  Ophthalmology  Orthopedic Surgery  Otolaryngology  Plastic Surgery  Thoracic Surgery  Urology  Vascular Surgery

17. 17 Step 1: Calculation of Baseline Practicing Physician Supply Federally Employed Except VA 1,485 Practice Site Out-of-State 4,212 Non-practicing physicians 2,664 Non-renewals 1,716 Currently Licensed Physician Supply 24,968 Adjusted Baseline Physician Supply 14,891 MINUS EQUALS Source: Maryland Board of Physicians

18. 18 Step 2: Calculation of 2007 Clinical Physician Supply Adjusted by % Clinical Status Adjusted Baseline Physician Supply 14,891 Adjusted by FT/PT Status Total Clinical Physician Supply 10,227 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.

19. 19 Step 4: Forecast Physician Supply for 2010 & 2015 Clinical Physician Supply 2007 Retirements/ Deaths Gender/ Lifestyle Net In-Migration Residents Remaining In MD Forecasted Clinical Physician Supply 2010 & 2015 MINUS EQUALSPLUS

20. 20 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

21. 21 Total Clinical Physicians per 100,000 Residents by Region Compared to State and National Levels US MD

22. 22 Percentage of Medical Specialists Age 60 and Older by Region 2007  Medical Specialties significantly impacted by retirements (age of the workforce)  Capital and Eastern regions have highest percentage of physicians over Age 60

23. 23 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

24. 24 Medical Specialty Requirements “ Pediatric sub-specialties are hard to find. Half the pediatric population in hospitals are on medical assistance or uninsured. If I see a complex MA patient in the clinic I get paid $15. If the hospital nutritionist sees the patient the hospital receives $80. Medical Director-Pediatric Program

25. 25 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

26. 26 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 address both competitive compensation & on call needs

27. 27 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.

28. 28 Summary of Findings

29. 29 Maryland Physician Workforce Study – Current Physician Shortages by Region 2007 CapitalCentralEasternSouthernWestern Primary Care*:Primary Care MDs Medical Specialty:Allergy Cardiology Dermatology Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Nephrology Neurology Psychiatry Pulmonary Medicine Rheumatology Hospital-Based:Anesthesiology** Diagnostic Radiology Emergency Medicine Neonatology Pathology Physical Medicine Radiation Oncology Surgical Specialty:General Neurosurgery Obstetrics/Gynecology Ophthalmology Orthopedic Otolaryngology Plastic Thoracic Urology Vascular Total851825 20 % of Shortages27.6%17.2%62.1%86.2%69% Legend Adequate Physician Supply Borderline Physician Supply Physician Shortage *Physician Only**Physician & Resident Model

30. 30 Maryland Physician Workforce Study – Current Physician Shortages by Region 2015 CapitalCentralEasternSouthernWestern Primary Care*:Primary Care MDs Medical Specialty:Allergy Cardiology Dermatology Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Nephrology Neurology Psychiatry Pulmonary Medicine Rheumatology Hospital-Based:Anesthesiology** Diagnostic Radiology Emergency Medicine Neonatology Pathology Physical Medicine Radiation Oncology Surgical Specialty:General Neurosurgery Obstetrics/Gynecology Ophthalmology Orthopedic Surg Otolaryngology Plastic Thoracic Urology Vascular Total1141727 % of Shortages37.9%13.8%58.6%93.1%75.9% Legend Adequate Physician Supply Borderline Physician Supply Physician Shortage *Physician Only**Physician & Resident Model

31. 31 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

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33. 33 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.

34. 34 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.

35. 35 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.

36. 36 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.

37. 37 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.

38. 38 Recruitment and Retention: Reimbursement POLICY RECOMMENDATIONS  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.

39. 39 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

40. 40 POLICY RECOMMENDATIONS  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. Retention of Maryland Residents in Training

41. 41 POLICY RECOMMENDATIONS  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. Retention of Maryland Residents (Cont’d.)

42. 42 POLICY RECOMMENDATIONS  Increase the number of residency slots. Retention of Maryland Residents (Cont’d.)

43. 43 Comments/Questions