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

2. Physician To Population Ratio

3. Primary Care Physician Supply

5. 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

6. Snapshot of Georgia: Race

7. Snapshot of Georgia: Gender

8. Do we have enough physicians in the pipeline to meet our need? o Impact of ACA o Number and training of medical school graduates in Georgia o GME programs in Georgia

9. 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

10. 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. “

11. HRSA: Projected Demand for Primary Care Physicians 20102020 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.

12. 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

13. 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

14. 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 11-16 YEARS POST HIGH SCHOOL TO EDUCATE A NEW DOC!

16. PHASES OF MEDICAL EDUCATION

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

18. Medical Schools in Georgia: 2014 SCHOOLANNUAL TUITIONESTIMATED # OF STUDENTS (2011-2012) TOTAL TUITION COSTS EMORY45,00051823,310,000 MCG24,72685221,066,552 MERCER41,45738716,043,859 MOREHOUSE36,9032308,487,690 GA-PCOM40,81239015,916,680 TOTAL2377$84,824,781

19. Training Challenges: Community Based Training Sites to support education 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 594 3 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 803 3 rd year medical students needing +/-3,212 off campus community based training with a CBF member.

20. Solutions: Provide tax credits for primary care community based faculty precepting 3 rd and 4 th year Georgia medical students. SB 391 was passed creating the first community based faculty tax deduction in the country. While not a tax credit, it did create the entry into the revenue system that could allow us to expand the deduction or convert to a credit. Off-shore and out-of-state medical schools are using Georgia CBF and paying them +/-$1500 per rotation. Rather than enter into a bidding war with these other players, a tax credit could provide a powerful incentive to Georgia CBF to only take Georgia medical, Physician Assistant, and Nurse Practitioner students.

21. 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 2007-2012. (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.

22. 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

23. 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…”

24.  Average debt $145,000 public med school and $180,000 private in 2008; total debt of all medical students $2 billion; NEJM Dec. 18, 2008.  Students entering now will graduate over $250,000 in debt.  In Georgia, tuition increases in last 5 years:  Emory $34,205 to $42,000 22.7%  MCG $10,772 to $21,408 98.7%  Mercer $27,876 to $39,885 39.5%  Morehouse $22,500 to $29,484 31.1%  PCOM $38,100 DEBT DISCOURAGES PRIMARY CARE GME

25. Number of Georgia Medical Students Staying In Georgia PC GME Residency Programs SpecialtyTotal of PGY 1 positions # of PGY 1positions filled / GA med stud. % of PGY 1 positions filled by GA med. Stud Family Medicine81911.1% Internal Med.1381913.8% Pediatrics552138.2% OB/GYN25624.0% General Surg.471123.4% Other Specialties4015213.0% Total747106 15.8% GBPW: Spotlight on Graduate Medical Education, February 2011 (for years 2010-2011)

26. Potential Strategies 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

27. GA ranks 39 th (we rank 9th in total population) GA would need 1,450 additional residency positions to match the natl. avg. GA would need 315 additional residency positions to match the Southeast avg. GBPW: Spotlight on Graduate Medical Education, February 2011 GASouth East AVG.NATL. AVG. 20.824.035.7 How does GA compare in it’s total # of medical residents /100,000?

28. 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

29. Shown another way… SCHOOLMEDICAL STUDENT AVERAGE ENROLLMENT PGY 1 RESIDENCY SLOTS (2011) EMORY150192 MEDICAL COLLEGE OF GEORGIA 205111 MERCER8969 MOREHOUSE5744 PCOM-GA85 OTHER62 TOTAL586478

30. Origins of GME Crisis in Georgia Medicare GME Capped (12/31/96 -BBA 1997) 1990-2010 Georgia grew 6.4-9.7 M +77% 1990-2010 USA grew 248-308 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

31. Number Of Georgia Residency Graduates Staying In Georgia 2012 Georgia GME Exit Survey Report, Georgia Board Physician Workforce, 2012 Key Findings: 50.0% are remaining in Georgia to practice 41.9% of all responding Georgia’s GME graduates going into practice in 2012 are going into primary care Of those that graduated high school in Georgia, 11.9% graduated from an overseas medical school 74.1% of graduates that graduated high school in Georgia and graduated from a Georgia GME program plan to stay in Georgia to practice Graduates that went to high school, medical school and GME in Georgia had an 81.8% retention rate The top reasons for graduates leaving Georgia are “Proximity to Family;” “Better jobs in desired location outside Georgia;” and “Better Salary offered outside of Georgia”

32. Distribution Of Medical Education Debt By Number And Percent, 2012 Amount of Debt Number Percent None 88 20.0 Less than $20,000 11 2.5 $20,000-$39,999 14 3.2 $40,000-$59,999 14 3.2 $60,000-$79,999 20 4.5 $80,000-$99,999 8 1.8 $100,000-$124,999 42 9.5 $125,000-$149,999 25 5.7 $150,000-$199,999 87 19.7 Over $200,000 132 29.9 TOTAL 441 100.0

33. GME Retention, Georgia 2012 Debt : In 2012, 29.9% of graduates had debt over $200,000 In 2006, 10.0% of residents had educational debt of over $200,000 Salaries of specialists were higher: ◦The average starting salary of graduates going into cardiovascular surgery was $321,000 ◦The average starting salary of graduates going into pediatrics was $132,125

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

35. Snapshot of Graduate Medical Education in Georgia For the Academic Year Beginning July 1, 2013 (GBPW, April 2014) Total Number of GME Positions in Georgia – 2,388 Total Number of GME Positions in Georgia filled – 2,195 (91.9%) – majority of vacant positions are in Anesthesiology, Family Medicine Internal Medicine, and Surgery and could be due to program expansions that have not been fully implemented.

36. Snapshot of Graduate Medical Education in Georgia For the Academic Year Beginning July 1, 2013 (GBPW, April 2014) cont… Total Number of PGY-1 Positions – 504 Total Number of PGY-1 Positions filled – 499 (99.0%) Total Number of 2013 GA Medical School Graduates – 558 with 547 entering GME programs Total Number of 2013 GA Medical School Graduates Entering GA GME Program – 122 (22.3%) Total Number of GA PGY-1 Positions Filled by Medical School Graduates from Outside GA – 377 (75.5%)

37. Snapshot of Graduate Medical Education in Georgia For the Academic Year Beginning July 1, 2013 (GBPW, April 2014) cont… Georgia ranks 40 th among the 50 states in total residents per 100,000 population (up from 41st in 2011 and still below the rank of 39th in 2009 and 37th in 2007). Georgia’s rate of 21.8 residents per 100,000 is well below the national average of 36.6 residents per 100,000. (Source: AAMC Center for Workforce Studies; 2013 State Physician Workforce Data Book; November 2013.)

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

39. 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  Address payment differentials immediately  Implement rural / primary care admissions tracks and curriculum at our medical schools

40. 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.

41. 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.

42. 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.

43. 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.

44. Two topics that have arisen this year are hosting mini-summits for the following topics: ◦Incorporating Nurse Practitioners and Physician Assistants into our deliberations- how can we partner with these groups to insure that these important primary care disciplines are also supported? ◦Educating and Motivating our Congressional Delegation to become more active and proactive in seeking federal solutions to the challenges facing the primary care workforce, to include GME slot distribution, federal funding of GME, and primary care payment differentials.

46. 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 706-721-8557 dkornega@gru.edu www.gru.edu/ahec