AMMENDED REPORT TO THE 2015 LEGISLATURE. Report on Findings from the Hawai i Physician Workforce Assessment Project

Transcription

1 AMMENDED REPORT TO THE 2015 LEGISLATURE Report on Findings from the Hawai i Physician Workforce Assessment Project Act 18, SSLH 2009 (Section 5) Act 186, SSLH 2012 January,

2 Hawai i Physician Workforce In accordance with Act 18, SLH, 2009 and Act 186, SLH, 2012 A report to the 2015 Hawai i State Legislature: Findings from the Hawai i Physician Workforce Assessment Project Prepared by: Kelley Withy, MD, PhD John A. Burns School of Medicine Area Health Education Center January

3 2014 Hawaii Physician Workforce Assessment Executive Summary The physician workforce in Hawaii has decreased from 2,894 Full Time Equivalents (FTEs) of physicians providing patient care in 2013 to 2,802 FTEs in This loss of nearly 100 physicians is believed by this researcher to be associated with the improved economic climate allowing for retirement, combined with the increasing requirements of clinical care due to changes in the healthcare system (electronic health records, ICD-10, eprescribing, etc). Utilizing a new projection model purchased from IHS Global, the minimum current demand, not taking into account shortages of Non-physician Clinicians in Hawaii or the oversupply of some specialties artificially decreasing demand, is 3,276 FTEs. When specialty-specific shortages are considered individually and the excess of physicians in areas of surplus are excluded from the calculation, the shortage of physicians is estimated at 655 full time equivalents. This indicates a continuing shortage of 20% of physician FTEs statewide. When the demand model that was created in 2010 is used, in order to compare current data with past data trends, the following table was produced: 2014 estimates Demand Supply Shortage % Shortage Total State % Big Island % Kauai % Maui County % Oahu % A best case scenario for future workforce numbers is that by 2020, Hawaii will have a shortage of 800 physician FTEs. A worst case scenario is a shortage of 1,500 physician FTEs. The physician specialties with the greatest shortages are primary care, particularly on neighbor islands, as well as the following specialties which have shortages of over 30% statewide: Infectious Disease, Colorectal Surgery, Pathology, General Surgery, Pulmonology, Neurology, Neurosurgery, Orthopedic Surgery, Family Medicine, Cardiothoracic Surgery, Rheumatology, Cardiology, Hematology/Oncology, and the Pediatric subspecialties of Endocrinology, Cardiology, Neurology, Hematology/Oncology and Gastroenterology. The specialties with the largest number of additional providers needed are Family Medicine (174 needed), General Surgery (57 needed), Pathology (44 needed), Internal Medicine (39 needed), Orthopedic Surgery (36 needed), Cardiology (32 needed), Anesthesia (31 needed) and Neurology (31 needed). In addition to researching the size of the physician workforce in Hawaii, the Physician Workforce Assessment special fund supported the following activities during the 2014 year: Hosting the Hawaii Health Workforce Summit and Job Fair for 340 participants; health careers recruitment activities including development of a Hawaii health careers pathway book; convening and co-chairing the Governor s Healthcare Transformation Workforce Meetings that include planning for a potential Hawaii Health Workforce Center; promoting jobs in collaboration with the Hawaii Physician Recruiters group; and continuation of the Hawaii State Loan Repayment Program new federal grant funding that expands loan repayment to 25 Behavioral Health and Primary Care providers once local funding is procured. 3

4 Hawai i Physician Shortage: Supply and Demand The supply of physicians in Hawai`i is estimated based on responses to a voluntary survey of physicians administered at time of state medical license application, queries of local community contacts, internet searches and direct calling of physician offices to confirm hours of active patient care. Data was obtained for 95% of the providers who report working in Hawaii. Of the 9,109 physicians licensed to practice in Hawaii as of October 22, 2014, only 3,594 physicians are actively practicing in non-military settings. The total full time equivalents of direct patient care provided by these physicians (including those providing telehealth to Hawaii patients from outside the state) is 2,802 FTEs. The demand for physician services is estimated using a model purchased from IHS Global in The major components of the demand model include: 1) a population database that contains characteristics and health risk factors for a representative sample of the population in each Hawaii county, 2) predictive equations based on national data that relate a person s demographic, socioeconomic and health risk factor characteristics to his or her demand for healthcare services by care delivery setting, and 3) national care delivery patterns that convert demand for healthcare services to demand for FTE physicians. For purposes of physician workforce modeling the relevant settings are physician offices, outpatient clinics, hospital emergency departments, and hospital inpatient settings. While the forecasting equations and staffing patterns are based on national data, a population database was constructed for Hawaii that was representative of the population in each Hawaii county. This was done using county-level population information (e.g., age-gender-race/ethnicity), whether a county was considered metropolitan or non-metropolitan, and information from the Behavioral Risk Factor Surveillance System (BRFSS) for the population, including summary statistics by county for factors such as prevalence of obesity, diabetes, current smoking status, and other risk factors used in the model. Applying the model to Hawaii, therefore, produced estimates of physician demand by select specialty if people in each county were to receive a level of care consistent with the national average, but adjusting for differences across counties in demographics, health and economic factors that affect demand for health care services. One adaptation was made based on Hawaii s geographic differences from the mainland. Two specialties, Emergency Medicine and Critical Care, were assessed at the 75 th percentile utilization level to adjust for the fact that there are geographically isolated hospitals which must have a minimal staffing level to function. While pediatric subspecialties are included in this table, additional research 4

5 must be done to confirm accuracy of both the demand model and the supply numbers as a new methodology was used to perform the demand and in most cases, a provider that works in a subspecialty will provide care to both adult and child patients, making it difficult to differentiate what percent of time is spent caring for pediatric patients. For example, while there is significant anecdotal unmet need for Child and Adolescent Psychiatry across the state, the numbers indicate there are adequate Child Psychiatrists practicing in Hawaii. It is possible that the Psychiatrists who have listed both Adult and Child/Adolescent Psychiatry are performing more Adult Psychiatry than Child/Adolescent Psychiatry. Additional research must be performed to confirm whether this is the case. Also of note is that there is not yet a category of demand for hospitalists, however because they are taken out of the primary care supply, they have been included in the Other category for both supply and demand until accurate estimates of demand are created. The specialties included in the other category are hospitalist, pediatric hospitalist, occupational medicine, sleep medicine, complementary and alternative medicine, pain medicine, preventive medicine and radiation oncology. Because the demand model is new this year, the assessment of change in specialties with the greatest shortages is not included in the report, however will be tracked using the new demand model from 2014 forward. The total estimated demand for physicians is 3,276 FTEs. Projections of future supply are difficult to assess as there is no clear indications of trends based on the four years of data available. Therefore the projections in the model offered are based on Hawaii being able to maintain our current physician numbers by replacing those who retire or leave every year. If this is the case, then by 2020 we will be 800 physicians short, if the physicians we have practice in the specialties most needed. Since this is rarely the case, it is likely that our shortage will increase more steeply that this graph represents. In addition, there is an assessment of physician assistants and advanced practice nurse practitioners currently underway and if these important patient care provider populations are also demonstrated to be at 50% of less of demand, as estimated by this researcher, then the demand for physicians will be even higher to make up for that shortage. Based on the calculations described above, the trends in physician supply and demand in Hawaii are graphed in Figure 1 below. 5

6 Physician Full Time Equivalents Figure 1. Trends in Physician Changes and Future Projections Supply Demand The supply and demand of different specialties on a statewide basis is outlined in Table 1 by specialty of greatest percentage of unmet demand. Remember when reading this table that the percent shortage is distinct from the number of providers needed, so that for specialties with low numbers, a single new provider can make a significant impact on shortage percent. Table 1: Statewide Supply and Demand Estimates 2014 Ranked by Percentage of Shortage Statewide Demand Supply FTE % Shortage Shortage Pediatric Endocrinology % Infectious Disease % Colorectal Surgery % Peds Card % Pathology % General Surgery % 6

7 Peds Neurology % Pulmonology % Neurology % Neurological Surgery % Pediatric Heme/Onc % Orthopedic Surgery % General & Family Practice % Thoracic Surgery % Rheumatology % Cardiology % Peds GI % Hematology & Oncology % Urology % Allergy & Immunology % Otolaryngology % Nephrology % Critical Care % Anesthesiology % Plastic Surgery % Gastroenterology % OBGYN % Vascular Surgery % General IM % Psychiatry % Pediatrics % Radiology % Endocrinology % Physical Medicine and Rehabilitation % Emergency Medicine % Dermatology % Ophthalmology % Child & Adolescent Psychiatry % Neonatal-perinatal % Pediatric Rheumatology % Geriatrics % Other: Hospitalist, CAM, Rad Onc, Prev Med, Pain % Total Table 2: Statewide Supply and Demand Estimates 2014 Without Excess FTEs FTE % Statewide Demand Supply Shortage Shortage Pediatric Endocrinology % 7

8 Infectious Disease % Colorectal Surgery % Peds Card % Pathology % General Surgery % Peds Neurology % Pulmonology % Neurology % Neurological Surgery % Pediatric Heme/Onc % Orthopedic Surgery % General & Family Practice % Thoracic Surgery % Rheumatology % Cardiology % Peds GI % Hematology & Oncology % Urology % Allergy & Immunology % Otolaryngology % Nephrology % Critical Care % Anesthesiology % Plastic Surgery % Gastroenterology % OBGYN % Vascular Surgery % General IM % Psychiatry % Pediatrics % Radiology % Endocrinology % Physical Medicine and Rehabilitation % Emergency Medicine % Dermatology % Ophthalmology % Child & Adolescent Psychiatry % Neonatal-perinatal % Pediatric Rheumatology % Geriatrics % Other: Hospitalist, CAM, Rad Onc, Prev Med, Pain % Total % 8

9 Table 3: Demand Ranked by Shortage of Full Time Equivalents Statewide Demand Supply FTE Shortage % Shortage General & Family Practice % General Surgery % Pathology % General IM % Orthopedic Surgery % Cardiology % Anesthesiology % Neurology % Pulmonology % Infectious Disease % OBGYN % Hematology & Oncology % Pediatrics % Psychiatry % Urology % Otolaryngology % Neurological Surgery % Gastroenterology % Nephrology % Thoracic Surgery % Peds Card % Rheumatology % Allergy & Immunology % Critical Care % Plastic Surgery % Colorectal Surgery % Pediatric Endocrinology % Pediatric Heme/Onc % Peds Neurology % Peds GI % Vascular Surgery % Demand by County The physician shortages are still greatest in the most rural areas of our state. The following four tables outline the supply and demand tables for each county of Hawaii. Further breakout can be provided upon request (for example by island within Maui) by ing withy@hawaii.edu. 9

10 Table 4: Hawaii Supply Demand Table Hawaii Island Demand Supply FTE Shortage % Shortage Colorectal Surgery % Neonatal-perinatal % Pediatric Rheumatology % Peds Card % Peds GI % Peds Neurology % Plastic Surgery % Neurological Surgery % Infectious Disease % Allergy & Immunology % Nephrology % Hematology & Oncology % Critical Care % Orthopedic Surgery % Pulmonology % Neurology % Pathology % Otolaryngology % Endocrinology % Urology % Rheumatology % Physical Medicine and Rehabilitation % Cardiology % Thoracic Surgery % Anesthesiology % Pediatric Heme/Onc % Psychiatry % General Surgery % Dermatology % General IM % Pediatrics % OBGYN % Gastroenterology % Radiology % Ophthalmology % Emergency Medicine % Child & Adolescent Psychiatry % General & Family Practice % Geriatrics % Other: Hospitalist, CAM, Rad Onc, Prev % 10

11 Med, Pain Pediatric Endocrinology % Vascular Surgery % Total % Table 5: Kauai Supply Demand Table Kauai Demand Supply FTE Shortage % Shortage Critical Care % Neonatal-perinatal % Pediatric Endocrinology % Pediatric Heme/Onc % Peds Card % Peds GI % Peds Neurology % Endocrinology % Vascular Surgery % Neurological Surgery % Thoracic Surgery % Rheumatology % Plastic Surgery % Pulmonology % Allergy & Immunology % Pathology % Neurology % Orthopedic Surgery % OBGYN % Cardiology % Dermatology % Hematology & Oncology % Urology % Infectious Disease % General IM % Nephrology % Physical Medicine and Rehabilitation % Geriatrics % General Surgery % Gastroenterology % General & Family Practice % Psychiatry % Radiology % Colorectal Surgery % Pediatrics % 11

12 Anesthesiology % Child & Adolescent Psychiatry % Emergency Medicine % Ophthalmology % Other: Hospitalist, Urgent, etc % Otolaryngology % Pediatric Rheumatology % Total % Table 6: Maui Supply Demand Table Maui Demand Supply FTE Shortage % Shortage Colorectal Surgery % Geriatrics % Neonatal-perinatal % Pediatric Endocrinology % Pediatric Heme/Onc % Pediatric Rheumatology % Peds Card % Peds Neurology % Thoracic Surgery % Rheumatology % Infectious Disease % Pathology % Critical Care % General Surgery % Neurological Surgery % Gastroenterology % Pulmonology % Neurology % Vascular Surgery % Psychiatry % Plastic Surgery % Ophthalmology % Allergy & Immunology % Endocrinology % Orthopedic Surgery % Urology % Hematology & Oncology % Emergency Medicine % Pediatrics % General IM % 12

13 Physical Medicine and Rehabilitation % Anesthesiology % Otolaryngology % General & Family Practice % OBGYN % Child & Adolescent Psychiatry % Cardiology % Dermatology % Nephrology % Other: Hospitalist, CAM, Rad Onc, Prev Med, Pain 0 0.0% Peds GI % Radiology % Total % Table 7: Oahu Supply Demand Table Oahu Demand Supply FTE Shortage % Shortage Pediatric Endocrinology % Infectious Disease % Colorectal Surgery % General Surgery % General & Family Practice % Pathology % Peds GI % Peds Card % Pulmonology % Neurology % Cardiology % Neurological Surgery % Endocrinology % Orthopedic Surgery % Pediatric Heme/Onc % Peds Neurology % Otolaryngology % Hematology & Oncology % Urology % Nephrology % Thoracic Surgery % Rheumatology % Anesthesiology % Allergy & Immunology % OBGYN % 13

14 Gastroenterology % Vascular Surgery % Child & Adolescent Psychiatry % Critical Care % Dermatology % Emergency Medicine % General IM % Geriatrics % Neonatal-perinatal % Ophthamology % Other: Hospitalist, CAM, Rad Onc, Prev Med, Pain 0 0.0% Pediatric Rheumatology % Pediatrics % Physical Medicine and Rehabilitation % Plastic Surgery % Psychiatry % Radiology % Total % 14

15 Solutions Being Implemented Efforts to grow the population of satisfied physicians working in patient care in Hawaii are many. The Physician Workforce Research Team held the first Physician Workforce Summit in 2010 in order to prioritize the interventions to initiate first. At the first Summit, ten solutions were identified as the most important interventions in Hawaii to improve the physician workforce. These are: Expand the pathway to health careers; Expand rural training opportunities; Support practice reform such as Patient Centered Medical Home; Interprofessional teamwork in practice; Payment reform; Rural payment differential; Community Involvement; Medical malpractice reform; Administrative Simplification; and Electronic Health Records. In 2012, with the reauthorization of the Physician Workforce Assessment activities and the emphasis on solutions created in Act 186, SLH 2012, the Physician Workforce Research team began closer collaboration with the Hawaii Medical Education Counsel which identified two additional activities: a state loan repayment program and an initiative to recruit Hawaii medical training graduates back to practice in Hawaii. Activities have been accomplished in all areas except for Rural Payment Differential, which has met with resistance in the changing medical insurance marketplace. The most notable successes of the Physician Workforce Assessment activities are listed below by category: 1) Expand the pathway to health careers: The Physician Workforce Assessment team has made contact with over 3,000 health professions students in the intervening year. Even more exciting, is the development of a 140+ page health careers booklet with information on all the health professions in Hawaii and local resources for pursuit of health careers which can be viewed at 2) Expand rural training opportunities: AHEC is working with the health professions schools in Hawaii to expand rural training opportunities and currently provides these to 25% of the medical school class and 10% of the UH nurse practitioner students. Efforts are being made to expand this and include Nursing, Public Health and Social Work students as well. 3) Support Practice Reform was addressed at the 2014 Hawaii Health Workforce Summit that offered eight hours of Continuing Education to the 340 participants. The Summit addressed New Models of Care, Payment Reform, Administrative Simplification, Interprofessional Practice and Telemedicine. 4) Interprofessional Practice was addressed at the Workforce Summit and Dr. Withy is a member of 15

16 the University of Hawaii Interprofessional education group that is doing an assessment of all interprofessional training in Hawaii. 5) Payment reform was also addressed at the Summit, and Dr. Withy has been a member of the Governor s Healthcare Transformation Task Force Multipayer Committee. 6) Rural Payment Differential-no action. 7) Community Involvement-the Physician Workforce Assessment team is working with the Hawaii State Rural Health Association to provide the welcome wagon for rural providers and to date has supported the welcome of 11 local healthcare providers. Hawaii State Rural Health Association is in discussion with Hawaii Island Healthcare Alliance to create a welcome event for new providers on Big Island. 8) Medical Malpractice Reform was introduced in 2013 and the impact is being studied, but is initially disappointing. Dr. Withy regularly recruits additional physicians to participate in the Medical Inquiry and Conciliation Panels. 9) Administrative Simplification-Dr. Withy researched the extent of prior authorization forms from the eight local health insurers in Hawaii and found that there are 536 different prior authorization forms for providers in Hawaii to complete. An article is planned in the 2015 Workforce edition of the Hawaii Journal of Public Health and Medicine. 10) Electronic Health Records-Dr. Withy is on the Physician Advisory Group of the Hawaii Health Information Exchange and assisting with research on what will help physicians adapt to electronic information collection. 11) The Hawaii State Loan Repayment Program has received an additional four years of funding at $311,875 a year for the period of 9/1/2014 through 8/30/2018. The 16 current loan repayers are continuing, but the federal funds must be matched by local funding, so there will be a legislative request in the 2015 legislative session for matching funds. Applications are being accepted for loan repayment at this time, but only if there is a source of local matching. 12) Finally, a pop-up exhibitor stand is being developed to recruit healthcare providers to Hawaii and will be used by recruiters attending conferences across the country as part of a collaborative effort on the part of the Hawaii Physician Recruitment Committee and the Hawaii Physician Workforce Assessment to recruit providers to Hawaii. All Hawaii graduates are offered information on job openings and we have a list of 53 mainland physicians to whom we regularly send employment information. 16

17 In addition to these activities, Dr. Withy is co-chair of the Governor s Healthcare Transformation Task Force Workforce Committee and has assumed the responsibility to host this committee which is examining how to create a Health Workforce Center for all health professions in Hawaii. Next Steps The Physician Workforce Research Team will continue to conduct the research and implement the solutions described above. Additional research will be conducted to identify who is entering and leaving the workforce, and assess both the Physician Assistant and Advanced Practice Nurse Practitioner workforce to enhance the accuracy of the demand for healthcare services. In addition, annual Health Workforce Summits are planned emphasizing systems and payment reforms and other factors that will improve provider recruitment and career satisfaction. The annual summit is now being combined with a job fair for medical providers, that is designed to get students and residents participating in regular career preparation activities (CV writing, contract review and interviewing skills) that will be offered by the Hawaii Physician Recruiters group upon request throughout the year. The web based job bank will be continued at and outreach for Hawaii positions will be introduced at medical conferences across the country. More information on ongoing and upcoming activities is available at the AHEC website: The AHEC office number is and Dr. Withy s direct office line at JABSOM is and is withy@hawaii.edu. 17

18 Appendix 1: Rating of 2014 Health Workforce Summit Evaluation completed by 103 physicians, 14 Nurse Practitioners; 1 Physician Assistant; 15 Nurses; 3 Residents; 2 Academic Faculty; 4 Administrators; 154 students, 1 staff and 1 industry partner. Do you currently have an Electronic Health Record? Yes 99 No 50 Do you currently work in an interprofessional practice? Yes 59 No 82 Do you deliver health care services via telehealth? Yes 9 No 140 Pre-post improvement of How much do you know about the following: self reported competency on 5 point scale I know how federal legislation will impact my practice..54 I know how to increase my personal work satisfaction..51 I know how to convert to PCMH..45 I know how to create an interprofessional practice..39 I know how to get paid for doing telehealth.90 I know what a practice based network is..92 I know what direct primary care is. 1 I know what a clinically integrated physician network is..74 I know about new practice models that I could implement. 1.1 Please rate the quality and helpfulness for the sessions you attended: 1 to 5 (highest) Emerging National Practice Models 4.2 Emerging Local Practice Models (panel) 3.7 Career Satisfaction 3.9 Preceptor training 3.9 Interprofessional Practice 4.2 How to get paid fortelehealth 3.6 Clinically Integrated Networks/ACOs 4.0 Direct Primary Care

19 Reviewing an Employment Contract 3.9 CV writing and interviewing 4.2 Local Transformation Panel (PCMH/Medicare) 3.8 What was the most beneficial part of this conference? Majority of the respondents said Networking with other Health Care professionals was the most beneficial part of the conference; learning different models of delivery for care; shared vision; Dr. Fromer s talk on Career Satisfaction; Telemedicine; Dr. Forrest s talk on Direct Primary Care; listening to Medical Student's experiences; Healthcare work book; career fair; Healthcare transformation Please suggest changes that could improve the conference: Majority of the respondents said that directions for parking needed to be given in advance and the event schedule needed to be posted online in advance; registration lines too long; different practice models; too much use of acronyms, made it hard to fully comprehend certain discussions; more interactivity with participants; hear more about providers less about physicians; need better time management; Telemedicine needed to have speakers from the private insurance companies; info on what reimbursement models are working best nationally; include a focus on the use of APRN's & PA's within the healthcare model; sessions were too long; holistic systems approach; more activities as opposed to only lectures; linking to local resources; summary sheets/handouts for sessions? draw prizes before shuttle; progress on the health careers publication; speakers from rural areas, urban counterparts may not understand problems we face; broader range of health professionals; include the patient's perspective; detailed specific sharing of local, successful transformation experiences Please tell us what you would like to have the Summit address next year/suggestions for physician workforce activities: Majority of the respondents said that the new changes (how and what has changed in past year) in legislation and healthcare reform needs to be addressed; more on Direct Primary Care; more information on Telehealth; loan forgiveness options; how to increase medical school enrollment; bring High School students to introduce them to Medicine and JABSOM, scholarship for outer island High School students to attend conference; create a clinical elders group and a clinical students group; multidisciplinary group practices; Role of primary care MD as leader/organizer of an interprofessional practice; New Medical Specialty - Integrative Medicine; more information for Nurse's (RN, APRN, NP); include the nurses on panels; include other healthcare workers on panels; reducing barriers to recruitment, retention and effective practice of non-physician clinicians; ideas on self-funded Direct Primary Care; overview of Physician Malpractice Insurance; liability insurance issues; how to establish a private practice, post-residency; Health Info Technology; develop better communication between Pharmacies, MD's, Government Rules; Alternative Medicine resources; International Health integrative medicine; Occupational medicine; Patient engagement; American College of Physician s neighborhood model; Statistics/evaluation of Electronic Medical Records in Hawaii. 19

20 Appendix 2: Proposed 2015 Physician Workforce Relicensure Survey Questions 1. Do you provide healthcare to patients in Hawaii? Yes No If no, please skip further questions 2. Do you primarily serve a military or military dependent population? Yes No 3. Are you still in training (internship, residency or fellowship)? Yes No 4. Are you primarily a hospital based physician (hospitalist, anesthesiologist, etc) 5. What is your primary specialty? Other specialty? 6. What is the primary location where you see patients? a. Address 1: b. Zip code c. Phone number d. address e. How many hours a week do you work at this address? a. Do you have a second practice location where you care for Hawaii patients? b. Zip code c. Phone number d. How many hours a week do you work there? e. Do you have an additional office(s) in Hawaii? Yes no 7. Please describe your practice type: a. employed by large group b. locums c. private practice 8. What is the size of your practice group (how many partners do you have including yourself)? or more 9. Do you provide care to Hawaii patients via telemedicine? Yes No 10. Comments and suggestions addressing the survey or the physician workforce needs in Hawaii: 20