NEW J ERSEY PHYSICIAN WORKFORCE TASK FORCE REPORT

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1 NEW J ERSEY PHYSICIAN WORKFORCE TASK FORCE REPORT A Report by: New Jersey Council of Teaching Hospitals J. Richard Goldstein, M.D., President Deborah S. Briggs, BSN, MBA, Senior Vice President, Health Policy and Advocacy

2 Workforce Policy Task Force Organizations Represented by Workforce Policy Task Force Members Advisory Graduate Medical Education Council B. Lynch Associates Board of Medical Examiners Center for State Health Policy, Rutgers University Committee of Interns & Residents/SEIU Healthcare Medical Society of New Jersey Assemblyman Herb C. Conaway, Jr., M.D. New Jersey Hospital Association Senator Joseph F. Vitale NJ Area Health Education Center NJ Department of Banking & Insurance NJ Department of Health & Senior Services NJ Department of Human Services Seton Hall School of Graduate Medical Education The Matos Group Touro University College of Medicine University of Medicine and Dentistry, New Jersey University of Medicine and Dentistry, New Jersey - Robert Wood Johnson Medical School Consultants: Center for Health Workforce Studies- University at Albany Association of American Medical Colleges, Center for Workforce Studies Brenna Snider, Research and Editorial Consultant - i -

3 Acknowledgements Many thanks to New Jersey Hospital Association for co-sponsoring this important project. The New Jersey Council of Teaching Hospitals would like to thank the following individuals for their time and expertise in Task Force deliberations: Linda Anderson J1 Visa Program Department of Health and Senior Services Dr. Howard Rabinowitz, MD Director, Physician Shortage Area Program Jefferson Medical College Thomas Jefferson University David Squire, Executive Director Utah Medical Education Council Melanie Taylor, Deputy Director Utah Medical Education Council Cheri Tucker, Executive Director Georgia Board for Physician Workforce Colette Caldwell, Statistical Research Analyst Georgia Board for Physician Workforce ii

4 About the New Jersey Council of Teaching Hospitals New Jersey Council of Teaching Hospitals (Council) is the State s premier teaching hospital network. Founded in 1986 to recognize the unique nature and special needs of teaching hospitals, this non-profit consortium consists of Atlantic Health, Cooper University Hospital, Hackensack University Medical Center, Meridian Health, Saint Barnabas Healthcare System, St. Joseph's Regional Medical Center, Somerset Medical Center, UMDNJ-University Hospital, University of Medicine and Dentistry of New Jersey, Catholic Health East/NJ, and Saint Peter's University Hospital. Together, the Council institutions represent more than 36,000 health care professionals and about 7,000 hospital beds; care for more than 414,000 inpatients and nearly 4.7 million outpatient visits each year which account for over 1.9 million patient days; total an aggregate budget in excess of $5.7 billion per year; and provide a significant amount of the state's charity care while constituting less than 20 percent of the state's hospitals. Two of New Jersey's Level I Trauma Centers are NJCTH hospitals, as are four of the state's seven Level II Trauma Centers. Council member institutions are dedicated not only to high-quality patient care, but to health professions education and sophisticated research as well. NJCTH hospitals train more than 1,500 resident physicians each year and work with a variety of medical schools. The Council s mission as an organization is to provide leadership in the development of Centers of Excellence in health care delivery, education, and research, and to serve as the optimal setting for the provision of outstanding patient care and for the education of health care professionals. 1

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6 3 Executive Summary

7 Executive Summary The New Jersey Council of Teaching Hospitals (Council), together with New Jersey s departments of Health and Senior Services (DHSS), Banking and Insurance (DOBI), Human Services (DHS), New Jersey Hospital Association, Medical Society of New Jersey, and numerous private organizations in 2007 established a Physician Workforce Policy Task Force (Task Force). The charge of the Task Force was: To undertake a needs assessment of current and future physician supply and demand, as well as distribution of physician practices across the state. To identify issues and barriers that impede the medical schools, teaching hospitals, state agencies, and the market at large in addressing physician shortages. To recommend specific strategies that address and correct health workforce shortfalls to ensure adequate access to health care services for New Jersey citizens for the next decade. Findings New Jersey is facing significant future shortages in both primary care and several specialty areas. In eleven years (2020) there is a projected shortfall of over 2,800 additional physicians beyond the current physician graduate medical education (GME) production pipeline representing a 12 percent gap in the physician supply versus the likely population demand for services. The shortage consists of approximately 1,000 primary care physicians and 1,800 specialists. Based on existing publications from the Rutgers Center for State Health Policy on physician workforce supplies, the DHSS on prenatal services, the scrubbed American Medical Association (AMA) databases, national physician ratios by specialty, and numerous other data sources, the Task Force concluded that there is a current shortage within primary care specialties, including family medicine, geriatrics, general surgery, and obstetrics. Within non-primary care specialties, neurosurgery and pediatric sub-specialties are the most alarming. Over seventy percent of all pediatric sub-specialties have serious shortages. To ensure New Jersey citizens have access to necessary physicians and clinical services in the future, the State of New Jersey, the medical schools, and all the teaching hospitals will need to form a centralized strategic planning alliance to ensure policy, regulations, funding, and recruitment/retention programs are put in place to manage the physician supply. The Study Process The Council retained the Center for Health Workforce Studies of the University at Albany (CHWS), who secured the forecast modeling expertise of the Lewin Group and Altarum Institute, to perform extensive review and modeling of the AMA Masterfile of Physicians, the New Jersey Board of Medical Examiners database, the AMA Resident database, the New Jersey Department of Labor and Workforce Development data, and the New Jersey Resident Exit Survey results. The Council embarked on parallel research of the Association of American Medical Colleges (AAMC) physician workforce data, other state health workforce activities, national physician to population ratios, and performed extensive literature searches to assess issues and proven solutions addressing physician shortages. The Council s Physician Workforce Policy Task Force, which interfaced with the project consultants, refined the baseline supply model and then defined the Most Likely Demand 4

8 Scenario from 2009 to 2020, weighing the most significant variables (health care reform, insuring the uninsured, New Jersey s economic growth, and increased efficiencies in the provision of medical care). After months of deliberation, the Task Force determined the following assumptions should be reflected in New Jersey s physician supply most likely demand model: Health care reform will begin by 2012, leading to major infrastructure, policy, and funding reforms by The current 250,000 uninsured children will be reduced steadily between 2009 to less than 25,000 by Uninsured adults will be reduced from the current 1,150,000 adults in 2009 to approximately 345,000 by The remaining uninsured will include New Jersey s undocumented immigrants and individuals who choose not to participate in available insurance programs. New Jersey s economic growth will decline by 2 percent in 2009 and will remain negative until 2013; thereafter, the economic growth incrementally improves reaching 2.5 percent economic growth by Clinical service efficiencies will occur, including the reduction of excess clinical tests and procedures; elimination of redundant diagnostic tests; enhanced communication through the use of information technology; and implementation of electronic health records. Together these reforms will improve efficiencies by 2.5 percent by This Most Likely Demand Scenario was then modeled against the baseline. Table 1: Most Likely Demand Scenario 2008 Current Supply* 2020 Projected Supply** Projected Shortage By 2020*** Baseline Supply Physician production, practice patterns, rates of separation from workforce, and migration patterns remain constant TOTAL PRIMARY CARE SPECIALISTS Anesthesiology Cardiovascular Diseases Emergency Medicine General Internal Medicine General Pediatrics General Surgery General/Family Medicine Obstetrics & Gynecology Ophthalmology Orthopedic Surgery Other Int. Med. Subspecialties Pediatric Subspecialties **** Other Specialties Other Surgical Specialties Otolaryngology Pathology Psychiatry Radiology Urology 22,410 8,233 14,177 1,406 1, ,825 2, ,869 1, , , , ,697 9,020 15,697 1,612 1, ,424 2, ,228 1, ,179 1, ,532 1, ,835-1,006-1, * Amounts include only post-residency, patient care physicians, which is about 94% of all licensed physicians (23,748). ** The amounts for Total, Primary Care, and Specialists were adjusted to take into account surpluses/shortages that likely exist (currently) in some specialty areas. The unadjusted baseline supply for 2020 is 26,274 (9,596 primary care; 16,678 non-primary care). *** The projected shortages are based on adjusted 2020 Projected Baseline Supply. **** Pediatric Subspecialists supply and demand data can be found on Appendix 10. 5

9 Insights Regarding Physician Data and the Determination of Supply and Demand The Task Force became frustrated with the absence of data to provide critical information which would clarify specific physician shortages, such as whether the practicing OB/GYN physicians in the state are actually performing deliveries. This lack of data created other negative consequences relating to qualifying for J-1 visa positions and federal loan repayment funding that the Task Force believed could be rectified if New Jersey instituted a mandatory re-licensure survey. This survey would provide vital data that could guide policy and funding decisions impacting future physician supply. Our goal was to identify the needed supply of primary care and specialty physicians over the next eleven years. The sophisticated forecasting models utilizing the CHWS and the Lewin Group provided baseline targets, but it was soon realized it is impossible to mathematically calculate several unknowns that will impact physician supply and demand in the future. These include the outcomes derived by federal and state health reform initiatives, the success of the Obama administration in restoring economic growth through the federal stimulus package, the impact of deploying IT integration and electronic medical records, the success of increasing the health care workforce through educational grants, and the ability to improve cost efficiency and clinical effectiveness through these broad based reforms. Nonetheless, New Jersey s need is daunting, with deficits in the best case scenario being a shortfall of 2,500 primary care and specialty physicians, beyond the current pipeline. The worst case scenario demonstrates the need of more than 3,100 physicians by With this variable target, the Task Force prioritized as the most important action, the creation of a central entity within the state to continually monitor and forecast supply and demand, as well as to manage and refine policy, programs, and strategies. A very deliberate, multi-faceted strategic action plan must be implemented expeditiously. Figure 1 provides an example of a multi-faceted policy and programmatic approach that could significantly address New Jersey s impending physician shortage. Figure 1 Example of a Programmatic Menu to Address Physician Shortages 6

10 The Task Force s Recommendations Goal I: Create or designate an organization, the Center for Medical and Health Workforce Planning, to continuously monitor, forecast, predict, and refine recommendations to ensure an adequate and well-dispersed supply of physicians and advanced practice practitioners for New Jersey. The Center will be responsible to perform (or subcontract with an entity to perform) the collection, analysis of multiple data sources, and comprehensive reporting on health workforce supply and demand trends. With this information the Center will guide the allocation of resources based on workforce needs, track physician and advanced practice provider shortages to determine graduate medical education (GME) and other funding priorities, manage vacant resident positions, direct funds to the individual programs with greatest impact on workforce needs, and provide incentives for teaching programs to retain graduates to practice in New Jersey. This Center would interface with the National Health Workforce Advisory Council to submit data and obtain federal grants that will support New Jersey s health workforce initiatives. Goal II: Expand retention and recruitment initiatives to encourage physicians to enter, remain in, or return to practice in New Jersey. New Jersey is competing with forty-nine states to recruit new physicians, as they address their state s physician workforce shortages. New Jersey must expand current workforce programs, improve New Jersey s practice environment, and establish financial incentives which offset the high cost-of-living and small business barriers inherent to the state, to be competitive. Our goal must be to foster innovation within existing programs and make certain we maximize federal programs and funding to ensure New Jersey is a viable state to practice medicine. Goal III: Align goals and incentives between the medical education stakeholders: medical schools, teaching hospitals, and the State of New Jersey. Reforms should focus on establishing strategic planning processes between the state, teaching institutions, and medical education leadership. Using data from forecasting models and data driven reports created by the Center, all stakeholders should work to ensure the medical education system is maintained or supported, the physician specialty training programs and residency counts are adjusted to address future physician workforce shortages by specialties, and collaborate on strategies to increase in-state retention. Goal IV: Enhance state funding for medical education and post graduate physician residency programs. 7

11 Graduate medical education in New Jersey cost $765 million in Of this, state Medicaid GME funding is only $60 million (including the federal matching dollars). Medicare funds approximately $340 million, leaving the balance to be paid by hospitals from foundation funds and operational margins. This Goal focuses on identifying sources for adequate funding that will then allow New Jersey to be more competitive. New Jersey must attract more students by increasing medical school capacity, it must adequately fund graduate medical training positions, it must address student medical education debt levels through viable programs, and the practice environment must be improved to retain or attract physicians seeking to establish their medical practice in this state. Goal V: Pursue federal reforms to address expanding GME resident slots to address workforce shortages, as well as systemic problems in GME funding mechanisms, administrative processes, and regulatory oversight. Medical education and healthcare workforce needs have changed over the past 15 years, while regulations and funding have not. For example, more training takes place in an outpatient setting; however, Medicare GME reimbursement is primarily inpatient drive. As the training model changes, the reimbursement methodology must be reformed. Additionally, the oversight system is over-complicated with costly rules and regulations that thwart logic and stifle innovation. GME resident position expansion, administrative, and funding systems must be addressed as national health system reform is being contemplated in Washington, D.C. Conclusion Ensuring that New Jersey has an adequate physician supply will not be easy. The physician shortage is a national problem, albeit less so in states that have established policies and programs to address their physician training and practice environment. Utah, Georgia, and other states have implemented state-financed physician retention and recruitment programs with documented success. New Jersey has several retention programs, but these initiatives function autonomously and are poorly funded. Meeting the five goals will require state and federal commitment, public and private partnerships, as well as significant political will and health leadership engagement, to address system improvements, identify funding sources, and establish recruitment and retention programs. Medical schools, teaching hospitals and academic medical centers, and state agencies must be willing to embrace change, reject traditional thinking, and participate in ongoing give and take in reform discussions. If these parties are successful, we can be assured that New Jersey s future physician and health care workforce will be able to meet the clinical and health care needs for all New Jersey citizens. 8

12 Table of Contents Tables and Figures Regional Definitions Introduction Section One New Jersey s Current Physician Workforce Section Two New Jersey s Medical Education Pipeline Section Three A Summary of New Jersey s Current Physician Supply Section Four Future Physician Need in New Jersey Section Five Task Force Recommendations End Notes Appendices 1. Acronym and Abbreviation Guide 2. Physician Mapping Document 3. Physician Supply and Distribution in New Jersey, 2008 (provided by CHWS) 4. Physician-to-Population Ratios Benchmarking Analysis (NJCTH) 5. Comparison of New Jersey Patient Care Physicians by Specialty per 100,000 (Rutgers CSHP) 6. Selected Recommendations of the New Jersey Health Care Access Study Commission 7. New Jersey Health and Senior Services- Medically Underserved Index 8. State Examples of Health Care Workforce Initiatives 9. Center for Medical and Health Workforce Planning, Utah and Georgia Models 10. New Jersey Pediatric Subspecialist Workforce 9

13 Tables and Figures Tables: Table 1: Most Likely Demand Scenario Table 2: New Jersey Active Patient Care Physicians, 2008 Table 3: Unmet Need of Family Medicine Physicians in New Jersey Table 4: Perceived Specialty Shortages and Surpluses of Physicians Table 5: Pediatric Sub-specialist Shortages in New Jersey, 2008 Table 6: Percentage of Active Physicians Who Are IMGs (Northeast), 2007 Table 7: Medical Education Comparison, 2006/07 Table 8: Number of New Jersey Residents/Fellows by Specialty, 1995/96 and 2006/07 Table 9: Origins of Physicians Training in New Jersey, 2006/07 Table 10: Comparison of Retention Rates in Surrounding States Table 11: Controllable vs. Uncontrollable Lifestyle Specialties Table 12: Ideal Practice Settings Table 13: Most Important Factors When Considering Practice Opportunities Table 13a: Adjusted Physician Supply Table 14: Most Likely Demand Scenario Table 15: Current Workforce Activities in New Jersey Figures: Figure 1: Example of a Programmatic Menu to Address Physician Shortages Figure 2: Proposed Federal Workforce Solutions Figure 3: Data Sources Used By Other States Figure 4: Rural Areas of New Jersey Figure 5: Primary Care Physicians Per 100K in New Jersey Figure 6: Breakout of New Jersey s IMG Residents/Fellows, 2008 Figure 7: Active Physician Supply Baseline Forecast: Figure 8: Active Physician Supply Baseline Forecast: Figure 9: Selected Assumptions of the Most Likely Demand Scenario Figure 10: Demand for Physicians in New Jersey,

14 Regional Definitions For purposes of this report, New Jersey s counties were aggregated into two regions (Northern New Jersey and Southern New Jersey), as depicted in the map below. Northern New Jersey counties: Bergen, Essex, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Passaic, Somerset, Sussex, Union, and Warren. Southern New Jersey counties: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Ocean, and Salem. Per Task Force recommendations, future endeavors will divide New Jersey into three regions: North (Bergen, Essex, Hudson, Hunterdon, Morris, Passaic, Somerset, Sussex, Union, and Warren); Central (Burlington, Mercer, Middlesex, Monmouth, and Ocean); and South (Atlantic, Camden, Cape May, Cumberland, Gloucester, and Salem). 11

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16 13 Introduction

17 Introduction An adequate supply and distribution of physicians is an essential component of an effective health care system. While there is no simple ratio to determine how many physicians a nation, state, or region should have, it is possible to evaluate the adequacy of physician supply within a particular geographic area by applying supply and demand forecasting models which inform key stakeholders on future physician and health care workforce needs. Due to the length of time and great expense required for physician education and training, it is prudent to anticipate likely physician supply and demand imbalances well in advance of their potential occurrence. In the fall 2007, The New Jersey Council of Teaching Hospitals (Council), together with New Jersey s departments of Health and Senior Services (DHSS), Banking and Insurance (DOBI), Human Services (DHS), New Jersey Hospital Association, Medical Society of New Jersey, and numerous private organizations established a Physician Workforce Policy Task Force (Task Force). The charge of the Task Force was: Undertake a needs assessment of current and future physician supply and demand, as well as distribution of physician practices across the state. Identify issues and barriers that impede the medical schools, teaching hospitals, state agencies, and the market at large in addressing physician shortages. Research and recommend specific strategies that will address and correct health workforce shortfalls to ensure adequate access to health care services for New Jersey citizens. The Council hired the Center for Health Workforce Studies of the University at Albany (CHWS), who secured the modeling expertise of the Lewin Group and Altarum Institute to perform extensive review and modeling of the American Medical Association (AMA) Physician Masterfile, the New Jersey Board of Medical Examiners database, the AMA Resident database, the New Jersey Department of Labor and Workforce Development data, and the New Jersey Resident Exit Survey results. The Council embarked on parallel research of the Association of American Medical Colleges (AAMC) physician workforce data, other state health workforce activities, national physician to population ratios, and performed extensive literature searches to assess issues and proven solutions addressing physician shortages. The Task Force, through the analysis and guidance of the project consultants, and presentations by subject matter experts, spent considerable time evaluating numerous physician supply and demand models, as well as potential solutions, including expanding the advanced practice nurse (APN) and physician assistant (PA) workforce, which could address New Jersey s impending physician shortage. BACKGROUND National Physician Shortage In January 2005, the federal Council on Graduate Medical Education (COGME) released its sixteenth report, Physician Workforce Policy Guidelines for the United States, The report detailed forecasts of national physician supply and demand that indicated a substantial shortage of physicians by The magnitude of the shortage was estimated at 85,000 to 96,000 physicians, or between 7.5 and 8.5 percent of the likely number of physicians required to provide services for the nation s population in With aging general and physician populations, a stagnant medical education and training effort, more than 4,000 designated primary care Health Professional Shortage Areas (HPSA), a decline in the growth of managed care payors not willing to continue supporting rising rates of physician utilization, and 14

18 reports from a dozen medical specialties of current or impending physician shortages, it no longer made sense to think in terms of physician surpluses. The COGME s report attempted to bring these observations together coherently. In 2008, the AAMC published The Complexities of Physician Supply and Demand Projections through 2025 which built upon COGME s study. Based on similar forecast models utilized by the Task Force, AAMC projected a physician shortage throughout the U.S. of up to 124,000 by One of the limitations of both the COGME and AAMC reports was their lack of attention to the regional and state specialty-specific variations embedded in its forecasts. Thus, one of the ramifications of the report was movement by concerned stakeholders in a number of states to determine how the projected national physician shortage would play out in their areas. Like New Jersey, other states have chosen to utilize nationally recognized forecasting models, such as the Health Resources and Services Administration (HRSA), to improve the evidence available for policy makers, workforce planners, and educators to make informed decisions related to medical education and training infrastructure. Using supply and demand forecasting models, states such as Arizona, California, Michigan, New York, North Carolina and Utah have studied or are examining physician workforce needs. Moreover, in the past several years, specialty-specific examinations in cardiology, endocrinology, allergy and immunology, psychiatry, neurosurgery, pediatric subspecialties, dermatology, medical genetics, radiology, geriatric medicine, and critical care have also yielded findings of current or future shortages of physicians. In 2009, signs continue to point toward worsening physician shortages and indicate that the U.S. is not producing enough doctors for its current and future needs. In recent testimony before the U.S. Senate, Richard A. Copper, M.D summarized the problem in simple terms: Too few physicians to serve the needs of the nation; too few generalists and too few specialists... too few physicians. 1 While states play a critical role in workforce activities, the federal government has done little in recent years to resolve current shortages or sustain a workforce for the future. This seems to be changing as Obama administration officials, who are alarmed at primary care physician shortages, are looking for ways to increase physician supply to meet the health care needs of an aging population and millions of uninsured people who could gain coverage under national health care reform legislation being championed by the president. A number of federal solutions have been discussed (Figure 2), and their likelihood of implementation should be more clear in the coming months. Figure 2. Proposed Federal Workforce Solutions Proposed Federal Workforce Solutions Increase Medicare payment to general practitioners Increase enrollment in medical schools and residency training programs Encourage greater use of nurse practitioners and physician assistants Expand National Health Service Corp, which deploys doctors/nurses to rural areas and poor neighborhoods Redistribute unused GME slots to increase access to primary care and generalist physicians Promote greater flexibility for residency training programs Create Temporary Assistance for Needy Families health professions competitive grants Develop a national workforce strategy that addresses shortages and encourages training in 15

19 New Jersey On January 11, 2006, Governor Richard Codey signed legislation that created the New Jersey Health Care Access Study Commission to study and develop specific recommendations regarding the most effective way to establish a health care system in New Jersey that provides access to health care for state residents which is affordable; is cost-efficient; provides comprehensive benefits; promotes prevention and early intervention; includes parity for mental health and other services; and eliminates disparities in access to quality health care. The Governor appointed 27 members to represent government, consumers, employers, unions, physicians, nurses, hospitals, health care associations, and health care insurance plans. The Commission s report, published in March 2009, outlined several workforce-related recommendations: develop a coordinated health care demonstration project; create the Office for Oversight of New Jersey s Health Care Workforce; address critical shortages of nurses and physicians; and increase Medicaid rates for health care providers. Other recommendations included: addressing the Health Care for New Jersey proposal; improving enrollment and preventing disenrollment in public health insurance programs; creating a guide to health care literacy; reducing language barriers to improve access; improving prevention and disease management; improving long-term care and end-of-life care; and improving strategies to keep coverage affordable while controlling cost (Appendix 6). In October 2006, New Jersey Governor Jon S. Corzine established the Commission on Rationalizing Health Care Resources as part of a process to evaluate and reform the state s health plan. The Commission s report 2 presented the poor financial state of New Jersey s hospitals and anticipated the closure of additional facilities in the short term. In early 2008, New Jersey DHSS Commissioner Heather Howard convened the Prenatal Care Task Force. Their charge was to review the adequacy of the prenatal care provider network and identify any regional or geographic barriers to care, as well as make recommendations on ways to improve access to early prenatal care and increase the number of women seeking and receiving care. 3 Having found the supply of providers inadequate, the Prenatal Care Task Force recommended that the number of obstetric providers and maternal fetal medicine/ perinatal specialists be increased in order to provide timely and adequate prenatal and obstetric services throughout the state. The Commonwealth Fund report, U.S. Variations in Child Health System Performance: A State Scorecard, reinforced this need when it found New Jersey ranked 42 nd in access to medical homes and primary care providers, and 29 th in the potential to lead healthy lives, compared to other states. Research conducted by the Rutgers Center for State Health Policy (CSHP) on the availability of physician services in New Jersey between 2001 and 2006 concluded that physician supply in a number of specialties was declining. 4 This research also found that the supply of physicians in New Jersey as a whole, as well as in many counties and specialties, was below the U.S. average and/or benchmarks at some point during the study period, with two counties (Cape May and Sussex) and two specialties (family medicine and hematology/oncology) below the benchmarks during the entire study period. See Appendix 5 for findings from this report. Avalere Health s 2006 report, entitled the New Jersey Health Care Almanac, found that the number of licensed physicians practicing certain specialties in the state declined in the past five years, particularly in obstetrics/gynecology, general surgery, and neurosurgery. With respect to nursing, the state is projected to have a 25 percent nursing shortage by 2010, and similar shortfalls are expected in various allied health professions. Anecdotal evidence from interviewees also suggested that there are existing shortages for certain kinds of allied health professionals, such as radiology technicians and other clinical support staff. Lastly, also in 2006, a survey of approximately 25 percent of all registered nurses (RNs) licensed in New Jersey was conducted by the New Jersey Collaborating Center for Nursing, 16

20 Rutgers College of Nursing, to provide insight on the state s nursing workforce. The study found that the nursing workforce is decreasing because of an inadequate pipeline of new nurses; an existing labor pool that is aging; a critical shortage of nursing faculty; and an alarming prevalence of job dissatisfaction and burnout. Moreover, about one third of New Jersey RNs will be retiring over the next ten years; thus, over 23,000 replacement RNs will be needed by 2016 just to maintain the current nurse supply. 17

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22 New Jersey s Current Physician Workforce Section One 19

23 New Jersey s Current Physician Workforce Section One AGGREGATE SUPPLY New Jersey has about 23,748 licensed physicians. Of those, 22,410 are post-residency, patient care physicians; 1,040 are primarily non-patient care physicians (research and administration); and 398 are residents or fellows in training (Table 2). This amounts to 253 patient care physicians per 100,000 population, which is above the state median ratio of Notable characteristics of the physician supply in New Jersey include: Nearly one-third (32 percent) are women. More than two-thirds (69 percent) are older than 45 years of age and 12 percent are 65 years of age and older. Forty percent are international medical graduates (IMGs); that is, they graduated from a medical school outside the U.S. and Canada. Nearly three-fifths (60 percent) graduated from a medical school in the U.S. or Canada, just 14 percent graduated from one of the three 6 medical schools in New Jersey; and slightly more than one-third (34 percent) completed graduate medical training in New Jersey. New Jersey physicians are, on average, more specialized. The ratio of medical subspecialties to population is much higher in New Jersey than in the U.S. 7 In addition, New Jersey s physician workforce is characterized by a higher than average number of active physicians nearing retirement; low medical school and physician training capacity; and low physician retention post graduation (likely due to the state s high cost of living, high medical malpractice premiums, and low Medicaid reimbursement). Appendix 3 contains physician supply and distribution profiles for each New Jersey County showing physicians by specialty, age, gender, IMG status, and retention. DATA SOURCES AND METHODOLOGY Sources The Task Force pulled from several sources to assess current physician supply and demand in New Jersey. To calculate the current baseline number of physicians, the following data sources were used: 2008 AMA Masterfile of Physicians New Jersey Board of Medical Examiners New Jersey Department of Labor and Workforce Development 20

24 Table 2: New Jersey Active Patient Care Physicians, 2008 Specialty Number #/100k Primary Care 8, Family Medicine 1, Internal Medicine 3, Pediatrics (general) 2, Geriatrics Primary Care Related 1, General Surgery Obstetrics and Gynecology Total 1, OB/GYN 1, GYN only Internal Medicine Specialties 2, Cardiology 1, Endocrinology & Metabolism Gastroenterology Infectious Disease Medical Oncology Nephrology Pulmonary Disease Rheumatology Other Internal Medicine Surgical Specialties and Subspecialties 2, Neurological Surgery Ophthalmology Orthopedics Otolaryngology Plastic Surgery Thoracic Surgery Urology Other Surgical Subspecialties Facility-based Specialties 2, Anesthesiology 1, Pathology Radiology Psychiatrists 1, Psychiatry- Adult 1, Psychiatry- Child & Adolescent Other 2, Allergy and Immunology Dermatology Emergency Medicine Neurology Pediatric Subspecialties Physical Medicine and Rehabilitation Preventive Medicine/Occ Med/Public Hlth Other Total 22, Notes: Number of physicians per 100,000 is based on New Jersey population of 8,859,780 See Appendix 3 for county-level physician supply data Sources: New Jersey Board of Medical Examiners; AMA Masterfile of Physicians; and New Jersey Department of Labor and Workforce Development 21

25 While the AMA Masterfile is the most comprehensive source of data on physicians in the U.S. and is frequently the source of data analyzed in state-level physician workforce assessments, it was determined by the Task Force that this database alone did not adequately reflect the physician supply in New Jersey. To more accurately describe the current physician supply and to seed the forecasting model inputs, a list of physicians licensed to practice medicine in the state was obtained from the New Jersey Board of Medical Examiners in June The list of licensed physicians was merged with the AMA s Masterfile of Physicians in order to attach demographic, education, and high level, practice characteristics to the licensed physicians. Based upon the practice address associated with each licensed physician, the list was scrubbed to better identify physicians who actually practice in New Jersey. Population, demographic, economic, and health status information about New Jersey was obtained from a variety of sources including the New Jersey Department of Labor and Workforce Development (population projections and characteristics); the Centers for Disease Control and Prevention s Behavioral Risk Factor Surveillance System (health status indicators); the Area Resource File (health care utilization estimates); the U.S. Census Bureau (insurance status indicators); and Rutgers University economists (economic projections). It should be noted, traditional physician supply and demand forecasting models start with a simple assumption: the model assumes physician supply and demand are currently equal. In other words, current physician shortages are not included in the baseline mathematical calculations. This assumption concerned our Task Force, so we challenged our consultants to include current shortages into the baseline model. Identifying Current Shortages Taking the Research to the Next Level Following the lead of other states, the Task Force sought additional information that helped show where, presently, New Jersey may be facing an insufficient supply of physicians. This included: Findings of published reports on New Jersey s availability of physicians services from Rutger s CSHP, New Jersey s Prenatal Care Task Force, and Avalere Health; Discussion on the perceptions of Task Force members with respect to shortage specialties and geographic mal-distribution within specialties; and Benchmarking analysis conducted by the Council using physician-to-population ratios by specialty and from multiple sources (e.g., HRSA, AMA, insurance companies, and professional associations). See Appendix 4. Considerations pertaining to data sources and methodology Benchmarks: County level benchmarking is useful because it sheds light on how physicians are geographically distributed throughout a state. Mal-distribution of physician supply is an important consideration since, within a specialty, there can simultaneously be an abundance of physicians in one geographic area and a severe shortage in another. There are, however, limitations to benchmarking. First, county level data must be weighted within current patient care practice and referral patterns. For example, shortages in Ocean County may be addressed by physicians in adjacent counties, since New Jersey counties are comparatively small. In addition, the ratios used in benchmarking often reflect national 22

26 Perceptions of Task Force members: The Task Force members were frequently asked to look beyond ratios and consider their perceptions with respect to physician shortages (e.g., recruitment difficulties, office visit wait times, etc.). In some instances (as noted throughout the report), the Task Force felt that the data did not always produce results that matched their experience of New Jersey s physician supply, despite reputable sources and careful scrubbing. Good, but imperfect data: In true New Jersey fashion, the Task Force doggedly pursued information that would enable them to make informed recommendations on how to address health workforce shortfalls. The group gathered and reviewed a great deal of relevant data to complete its task. However, it was apparent during the process that some desired data simply does not exist, and that New Jersey s data collection on physician workforce issues is minimal. Thus, for future analyses, the Task Force is committed to exploring additional data sources/methodologies that more accurately profile physicians in terms of overall supply, practice characteristics, practice location, specialty, demographics, and years to retirement. Inspiration comes from other states that rely more on primary research data through customized physician surveys, often collected during the medical re-licensure process (Figure 3). Figure 3. Data Sources Used By Other States Georgia: The Georgia Board for Physician Workforce (GBPW), a state agency, gathers information on practicing physicians, graduating residents and medical students, and graduates of family practice programs. Physician data is obtained through a survey completed at the time of medical license renewal that yields information on physician demographics, practice location, and specialty distribution. The survey, which has a 100 percent response rate, also helps Georgia establish a real number of practicing physicians by identifying those who are licensed, but actually retired and/or practicing in another state. In 2006, 25,724 physicians renewed a license in Georgia, but only 18,422 were actually found to be working in the state. See Appendix 8. Massachusetts: The Massachusetts Medical Society (MMS) takes a lead role in studying physician workforce by conducting seven surveys of the following groups to evaluate the status of the state s current workforce: practicing physicians, medical staff presidents, department chiefs in teaching hospitals, medical directors of medical groups, residency/fellowship program directors, physician offices (regarding appointment wait times), and residents (regarding patient access to care). North Carolina: The North Carolina Health Professions Data System (HPDS) is unique in that it contains over 30 years of continuous, complete data on the state s licensed health care professionals. Data collected, for most professions, include name, home/business address, birth year, sex, race, basic professional education information, specialty, activity status, form of employment, practice setting, total hours worked in an average week and percent time in direct patient care. In fiscal year , costs to maintain licensure data files were just under $120,000. See Appendix 8. Utah: The Utah Medical Education Council (UMEC), a quasi-governmental agency, studies the supply and distribution of physicians using surveys done in conjunction with medical license renewal. UMEC also collects data on other health professions, including dentists, podiatrists, physician assistants, pharmacists, registered nurses, the laboratory workforce, and radiology technicians. See Appendix 8. Rural/Urban areas: According to official U.S. Census Bureau definitions, rural areas comprise open country and settlements with fewer than 2,500 residents. Urban areas comprise larger geographic environments that are densely settled areas, but they do not necessarily follow municipal boundaries. Most counties, whether metropolitan or nonmetropolitan, contain a combination of urban and rural populations. With respect to physician workforce, rural and smaller metropolitan areas have trouble recruiting and retaining physicians since they tend to be isolated (geographically, socially, and professionally) and sometimes lacking in the quality and volume of services and amenities. 8 Specialists, in particular, are unable to attain economic viability, as well as the necessary resources (e.g., hospitals, laboratories, technology, etc.), to support a specialty practice in these areas. Shortages in urban areas tend to be a function of language, insurance status, 23

27 and health care system design rather than total numbers of physicians. While New Jersey is considered almost entirely urban by federal definitions, like HRSA, nearly 6 percent of the state s population reside in rural areas (Figure 4) and two thirds of the state is open space. The lack of federal HPSA 9 designations clouds the reality that New Jersey does indeed have rural pockets, particularly in the south and northwestern parts of the state. The New Jersey Primary Care Association has spent considerable time in developing a rural definition that would meet the needs of New Jersey. Ten counties qualify as rural under this definition: Atlantic, Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Ocean, Salem, Sussex, and Warren. Nonetheless, to improve our understanding of physician shortages, additional data will need to be collected and analyzed in the future related to reduced patient care hours, limiting patients with specific insurance coverage, and/or limiting scope of practice both in rural and urban areas. Figure 4: Rural Areas of New Jersey The U.S. Census Bureau defines a rural area as having fewer than 2,500 residents, and classifies as rural all territory outside urban areas. The map (at right) shows the rural (yellow) versus urban areas (green shades) of New Jersey. Rural areas (fewer than 2,500) Census urban area (2,500 9,999) Census urban area (10,000 49,999) Census urban area (50, 000 or more) Source: U.S. Department of Agriculture (Economic PRIMARY CARE PHYSICIANS Nationally, there are signs pointing toward an uncertain future for the supply of primary care physicians. A recent survey by The Physician s Foundation found that 78 percent of physicians believe there is a shortage of primary care doctors. 10 A study published in the Journal of the American Medical Association found that only 2 percent of graduating medical students say they plan to work in primary care (internal medicine), opting instead for specialties offering better quality of life and financial rewards. 11 Moreover, results from the 2009 National Resident Matching Program showed that medical students interest declined in family medicine (89 fewer), internal medicine (11 fewer), and pediatrics (7 fewer), as a shaky economy and the prospect of high medical school debt appear to be luring graduates into specialties other than primary care. An area of primary care that is particularly on alert is geriatric medicine. In its recent report entitled Retooling for an Aging America: Building the Health Care Workforce, the Institute of Medicine (IOM) states that the currently insufficient supply of health care professionals who care 24

28 for older adults will not come close to satisfying the increased demands expected in the future. 12 The 7,128 physicians who are certified geriatricians in the U.S. (or one for every 2,546 older Americans) are estimated to increase to only 7,750 in 2030 (or one for every 4,254 older Americans), far short of the total predicted need of 36,000 for that year. Despite the fact that many health care providers deem work with older patients as highly satisfying, there seems to be a national shortage of geriatricians and many geriatric fellowship positions remain unfilled due to it being a specialty characterized by low compensation, unglamorous work, a lack of mentors, and various financial disincentives. The fill rate of geriatric medicine training positions was only 54%. 13 In New Jersey, there are approximately 8,324 primary care physicians 14 providing clinical care (out of a total of 8,698 who are licensed). This ratio equals 94.0 primary care physicians providing clinical care per 100,000 people. One would initially assume that primary care physician supply is adequate since New Jersey s ratio is above the national average (88.1) 15. However, statewide totals ignore mal-distribution of primary care physicians in specific regions and/or counties. A closer look at the individual primary care specialties reveals insufficiencies (Figure 5). Figure 5: Primary Care Physicians Per 100K In New Jersey Figure 5 illustrates how the primary care physicians per 100,000 people compared, by county, to the national average ratio (88.1). The ratios in New Jersey s 21 counties range from a low of 57.8 primary care physicians per 100,000 people (Sussex County) to a high of per 100,000 people (Mercer County). Twelve counties fall below the national average, including all but one county (Camden County). This suggests poor distribution of primary care providers in the state, particularly in the south, rather than a total supply problem. The 2008 New Jersey Resident Exit Survey also hints at potential deficiencies in the primary care workforce pipeline. The respondents choosing primary care (both residents entering patient care/clinical care and those continuing training for sub-specialization) were below the average number of respondents, compared to previous annual surveys. Of the residents entering patient care, those in primary care specialties were more likely to practice in suburban and inner city areas (42 and 25 percent, respectively) than in small cities or rural towns (14 and 6 percent, respectively). They were also more likely to leave the state altogether (60 percent) than the non-primary care residents (45 percent). 25

29 In particular, the Task Force sensed that the supply of family physicians in New Jersey was insufficient, and a number of signs point toward an inadequate supply: The New Jersey Academy of Family Physicians believes that family medicine physicians remain undervalued and under fire and that there is a shortage of family physicians and primary care in the state. 16 A Rutgers CSHP study found that the state s family practice supply fell below national averages or published benchmarks in all study years. 17 The American Academy of Family Physicians (AAFP) predicted a shortage of family medicine physicians and suggested a family physician-to-population ratio of 41.6 in order to meet the nation s primary care needs (based on the assumption that family physicians will make up half of all generalists). For New Jersey, this means that 2,680 family physicians would be needed in 2006 and 3,551 in A Rutgers CSHP analysis reported a 12 percent drop in family medicine residents in New Jersey over the past 12 years (230 to 203), compared to a 2 percent increase nationally. 19 Benchmarking completed by the Council (Appendix 4) also confirmed current supply deficiencies in family medicine. There are 1,869 family physicians providing patient care in New Jersey (or 21.1 per 100,000 population), which is well below national averages and recommendations. Applying a ratio of 26.5 (i.e., average of five ratios for family medicine physicians) reveals a statewide deficiency with 13 counties below the benchmark, including almost every county in Northern New Jersey (Table 3). Applying the 41.6 ratio recommended by AAFP puts all but one county (Hunterdon) below the benchmark. TABLE 3: Unmet Need of Family Medicine Physicians in New Jersey (Amounts represent patient care physicians only) CURRENT 2020 County # #/100k Average Ratio Unmet Need (# physicians) AAFP Ratio Unmet Need (# physicians) Bergen Essex Hudson Hunterdon Mercer Middlesex Monmouth Morris Passaic Somerset Sussex Union Warren Northern NJ 1, ,478.5 Atlantic Burlington Camden Cape May Cumberland Gloucester Ocean Salem Southern NJ NEW JERSEY 1, ,816.7 Based on U.S. trends, New Jersey is one of many states needing more geriatricians to meet the demands of its expanding older population. At present, the entire state has about 91 geriatricians, or a density of 8 per 100,000 older adults. Projections conducted by the American 26

30 Geriatric Society (AGS) show that New Jersey s current geriatrician shortfall is 178 physicians. New Jersey will need to train an additional 536 geriatricians by 2030 to meet the projected future demand of our senior population. 20 Using ASG recommended ratios, the Council benchmarking indicated an insufficient supply of geriatricians in every New Jersey county (Appendix 4). The specialties of general surgery and obstetrics/gynecology (OB/GYN) were included in discussions on New Jersey s primary care workforce since both groups see a variety of medical conditions and increasingly perform more traditional primary care functions (e.g., first contact, care coordination, etc.), especially in rural and underserved populations. Across the state, benchmarking completed by the Council showed current surpluses for OB/GYN and general surgery, with the only exception being a shortage of surgeons in Southern New Jersey (Appendix 4). It should be noted that the Task Force questioned results pertaining to OB/GYN physicians. The consensus was that the supply of OB/GYN physicians performing deliveries, a group challenged by rising malpractice premiums, is insufficient and that further analysis must be completed to better understand gynecology and obstetrics as separate specialties. Possibly, by combining these physicians, the real supply of obstetricians is being overstated. Lastly, it will be critical for states that are looking to adopt universal health care insurance coverage, like New Jersey, to ensure an adequate and well-distributed primary care workforce. Massachusetts implementation of universal coverage legislation in 2006 led to a primary health care bottleneck when there were not enough health professionals serving in the right places to meet the increased needs of the state s newly insured population. Community health centers, which target the health care needs of the medically underserved, are playing a critical role in caring for the newly-insured patients while simultaneously serving as the primary care safety net for uninsured residents. Between 2005 and 2007, the total number of patients at health centers within Massachusetts rose by 50,000. New Jersey has 19 federally qualified health centers (FQHCs) with 99 satellite sites, which are the major provider of comprehensive community-based primary health care. In 2008, they served 366,785 persons and provided over 1,133,366 medical and dental visits. 21 SPECIALIST PHYSICIANS While primary care is often the focus of physician workforce debates, evidence at the nationwide level shows that some specialty physicians also may be facing a crisis. Studies by medical specialty organizations, state medical societies, and state workforce task forces have documented a need in many specialties, including anesthesiology, cardiology, emergency medicine, gastroenterology, nephrology, pediatric subspecialties, pulmonary, hematology/oncology, radiology, and rheumatology. 22 In a national survey of medical school deans and state medical societies, shortages were most frequently cited in anesthesiology and radiology (Table 4). 27

31 Table 4. Perceived Specialty Shortages and Surpluses of Physicians JAMA, December 10, 2003, Vol. 290, p2993. Copyright 2003, American Medical Association. All rights reserved. A 2002 NACHRI survey found that a shortage of pediatric subspecialists may become the top strategic and operational issues facing children s hospitals. Endocrinology, paleontology, and neurology had the highest vacancy rates while neurology and gastroenterology presented the greatest recruiting challenge. 23 According to the American Academy of Pediatrics, the most pressing issues in pediatrics are the geographic mal-distribution of physicians, mainly in rural and urban underserved areas, and supply gaps in most of the pediatric subspecialties. 24 In New Jersey, physicians tend to be more specialized, and the ratio of medical subspecialties is notably higher in the state than nationally. Contributing factors may include: High population, density crowded states and metropolitan areas tend to have more specialists and fewer primary care physicians. High per capita income specialists tend to congregate in high income regions where citizens can afford more specialist visits, mainly for elective procedures. On average, a 1 percent increase in per capita income leads to a.66 percent increase in demand for specialty services. A pipeline (i.e., medical education and teaching hospitals) geared toward specialty care. High public education expenditures per pupil- there is speculation that educated people may gravitate towards specialists (and specialist careers). In New Jersey, expenditure per pupil was the second highest in the US at $14,630 in Similar to primary care, a collective look at New Jersey s specialist physicians can be deceiving since it ignores shortages that persist in specific geographies. Signs point toward shortages in some specialties. In addition to family practice, Rutgers CSHP found that New Jersey physician supply between 2001 to 2006 fell below Weiner 26 benchmarks in the specialties of hematology/oncology, pediatric subspecialties, and emergency medicine and fell below U.S. supply (i.e., physician ratios per 100,000 population) in hematology/oncology, general surgery, neurological surgery, orthopedics, otolaryngology, thoracic surgery, pathology, radiology, 28

32 diagnostic radiology, vascular surgery, nuclear medicine, psychiatry, emergency medicine, and general preventive (Appendix 5). Benchmarking conducted by the Council, using 2008 physician data, found statewide deficiencies in dermatology, emergency medicine, hematology/oncology (South only), and neurology (South only), as well as in 73 percent of pediatric subspecialties (Appendix 4). While the supply of psychiatrists in New Jersey appeared sufficient, the Task Force s perception was that it is difficult to get appointments with these physicians and that more investigation is needed to confirm whether insurance issues or poor geographic distribution is fueling this problem. Table 5 shows the widespread shortages in the pediatric subspecialties. Statewide, physician supply was below benchmark levels in 19 out of 26 subspecialties. Southern New Jersey was most heavily impacted by deficits, showing shortages in areas where the rest of the state appeared to have sufficient supply (e.g., anesthesiology, child neurology, and orthopedics). Ben In addition, the New Jersey Council of Children s Hospitals determined the lack of pediatric subspecialists is a critical state issue and has identified the following pediatric subspecialties as having the most critical shortages based on wait times for appointments: child/adolescent psychiatry (Medicaid), child neurology, behavioral psychology, developmental pediatrics, neurosurgery, orthopedic surgery, otolaryngology, diagnostic radiology, cardiology (South only), endocrinology (North only), gastroenterology (North only), general surgery, urology (Medicaid), and dentistry (Medicaid). Table 5. Pediatric Sub specialist Shortages in New Jersey, 2008 Pediatric Subspecialties North NJ South NJ Adolescent Medicine Allergy Anesthesiology Cardiology Child Neurology Critical Care Medicine Developmental Behavioral Emergency Medicine Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Internal Medicine (Pediatrics) Nephrology Orthopedics Pulmonology Radiology Rheumatology Sports Medicine Results are based on benchmarking analysis done by New Jersey Council of Teaching Hospitals The following specialties did not show shortages: child and adolescent psychiatry, neonatalperinatal care, ophthalmology, otolaryngology, pathology, surgery, and urology INTERNATIONAL MEDICAL GRADUATES (IMGs) IMGs provide a steady and significant supply for the U.S. physician workforce, representing a quarter of all physicians. Compared to U.S. medical graduates (USMGs), IMGs tend to be older (by about 3 years), have a higher number of years since graduation from medical school (by about 5 years) and have a practice specialty of internal medicine. 27 IMG contributions span 29

33 direct patient care as well as academic medicine and research, and are unsurpassed in two distinct areas: IMGs are more willing to practice in underserved areas through J-1 visa waivers IMGs are more likely to possess a greater sensitivity to cross-cultural issues The primary IMG specialties include: anesthesiology (29 percent), internal medicine (36 percent), psychiatry (31 percent), pediatrics (28 percent), general surgery (20 percent), radiology (19 percent), family medicine (18 percent), and OB-GYN (18 percent). 28 In terms of practice location, IMGs tend to locate in the same state as where they completed their GME training, practice where IMG networks already exist, and locate in communities with higher proportions of the people of the same ethnicity. 29 In New Jersey, IMGs are a large component of the physician workforce. AAMC reported that nearly 40 percent of licensed, active physicians in New Jersey are IMGs, placing it first among the 50 states (Table 6). Moreover, 59 percent of the residents/fellows are IMGs (see next section), with the highest concentration of IMG residents/fellows located in psychiatry (77%) and primary care (73%). 30 TABLE 6: Percentage of Active Physicians Who are IMGs (Northeast), 2007 Rank State % Active Physicians 1 New Jersey 39.9% 2 New York 39.5% 7 Delaware 27.4% 8 Maryland 26.9% 9 Connecticut 26.8% 16 Pennsylvania 22.0% SOURCE: 2007 State Physician Workforce Data Book (AAMC) Notably, a large and growing component of IMG residents/fellows (59 percent) are either a U.S. citizen or permanent resident (Figure 6), most often enrolling in Caribbean medical schools. These medical students often return to the U.S. for clerkships in years 3 and 4. New Jersey provides 290 clerkship positions for these Caribbean schools, with 60 percent of the positions currently being utilized. Figure 6: Breakout of New Jersey's IMG Residents/Fellows, 2008 USMGs 41% IMGs 59% US-Born Citizen 12% Naturalized/Permanent Resident 22% Temporary Visa 13% Unknown 11% NOTE: Sum of parts do not equal total IMGs due to rounding. Many IMGs with temporary visas use the Conrad State 30 Program to establish a medical practice in the U.S. This program facilitates foreign physicians on J-1 visas to avoid a requirement that they leave the nation for two years before they apply to return, provided they agree to practice in medically underserved communities for three years. In 2007, New Jersey s 30

34 Conrad State 30 Program placed five J-1 doctors (out of 30 allotted), mostly in children s hospitals. Despite numerous contributions to the physician workforce, it is increasingly difficult for immigrant physicians to practice medicine in the U.S. due to: Difficult entry requirements, especially after terrorist attacks on September 11, 2001; Language barriers; Drastically different professional and doctor-patient relationships; and Steep learning curves (e.g., hundreds of new brand names and laboratory values). There is also belief that IMG dependency discourages investments in cultivating future aspiring U.S. physicians and raises moral issues. A key moral question: Is the U.S. decreasing the physician workforce supply within non U.S. countries, thus harming the availability of physicians to provide necessary health care for their country of origin s population? This debate, along with the sometimes poorly documented retention rates of IMGs in shortage areas, has forced states to question their future reliance on IMGs to boost physician supply. 31

35 32

36 Section Two New Jersey s Medical Education Pipeline 33

37 Section Two New Jersey s Medical Education Pipeline For all states, the most convenient and logical source for future physicians is those who attended in-state medical schools or those who obtained graduate medical training in their state. 31 UNDERGRADUATE MEDICAL EDUCATION (UME) New Jersey has 3 medical schools (2 allopathic and 1 osteopathic) and one school (allopathic) under development, Touro University College of Medicine, due to open in the fall of During the 2006/07 academic year, 1,762 medical students were enrolled in these three schools. 32 Compared to other parts of the country, New Jersey lags behind in medical school capacity. A CHWS report completed for the Task Force profiling New Jersey s medical education and training found: Low Enrollment Levels. Despite a 1.4 percent increase in enrollment over the last decade, New Jersey has far fewer medical students compared to other states (Table 7). Falling Graduation Rates. New Jersey experienced a 6 percent increase in medical school graduates, amounting to 22 additional annual graduates in 2006/07 compared to 1995/96. However, taking into account population changes, this was a 3.4 percent decline, moving from 4.8 medical graduates per 100,000 to 4.6 (Table 7). Low Matriculation. Of New Jersey residents applying to U.S. medical schools in 2007, 20.5 percent matriculated in-state, 23.9 percent went out-of-state, and 55.6 percent did not matriculate. Comparatively, 30.6 percent of New York and 27.3 percent of Pennsylvania residents stayed in-state. 33 TABLE 7: Medical Education Comparison, 2006/07 NJ Mid- Atlantic (NY and PA) Northeast (CT, ME, MA, NH, RI, & VT) Enrolled medical students per 100K Medical graduates per 100K Residents/Fellows per 100K US Source: Center for Health Workforce Studies GRADUATE MEDICAL EDUCATION (GME) In 2007, there were about 2,636 resident and fellow training positions in New Jersey. Despite some growth (6 percent) in the number of physicians in graduate medical positions in the state over the past decade, New Jersey continues to lag behind in its capacity to train physicians relative to its neighbors and the nation as a whole. The national average for graduate medical training capacity is 35 training positions per 100,000 people. In New Jersey, the capacity in 2007 was 30 training positions per 100,000 people (Table 7). Further, compared to neighboring 34

38 states in the Northeastern US, New Jersey lags even further behind their average capacity of 62 training positions per 100,000 people (Table 7). Table 8 shows the changes in the number of residents/fellows training in New Jersey between 1995/96 and 2006/07. Comparing this data to the Task Force s list of targeted shortage specialties (see Section Three), there was growth within the state in many of the areas that currently have insufficient supply (e.g., emergency medicine, general surgery, obstetrics/gynecology, neurology, and pediatric subspecialties). The 17 percent growth in pediatric subspecialists, however, was marked by only 2 physicians. Unfortunately, the GME pipeline does not look as favorable for family medicine and psychiatry, where trainees fell by 12 percent and 8 percent, respectively, and both were below the national percentage changes for the same period. TABLE 8: Number of New Jersey Residents/Fellows by Specialty, 1995/96 and 2006/07 Specialties in red may currently be in short supply 1995/ /07 State Change National Change Primary Care Family Medicine % 2% Specialties Internal Medicine % 5% (or those largely Pediatrics % 8% providing primary care functions) Geriatrics* % -13% Obstetrics and Gynecology % -5% General Surgery % -7% Hospital-based Anesthesiology % 6% Specialties Emergency Medicine % 56% Pathology - Anatomic and Clinical % -17% Radiology - Diagnostic % 7% Surgical Colon and Rectal Surgery 3 3 0% 34% Specialties and Subspecialties Neurological Surgery 0 9 4% Ophthalmology % -24% Orthopedic Surgery % 11% Otolaryngology % 7% Plastic Surgery 6 6 0% 32% Thoracic Surgery % -18% Urology % -9% Surgical Subspecialties % 39% Internal Medicine Subspecialties % 20% Pediatric Subspecialties % 75% Combined Specialties % 37% Other Allergy and Immunology 4 4 0% 8% Specialties and Subspecialties Dermatology % 26% Neurology % 4% Physical Medicine and Rehabilitation % 3% Preventive Medicine % -34% Psychiatry % -6% Transitional Year % -17% All Others % 41% Total 2,507 2,636 5% 7% Sources: State-level Data for Accredited Graduate Medical Education Programs in the U.S., 1995/96 and 2006/07. AMA. *Geriatrics data are for the years 1998 and 2008; source is the state-level data for accredited GME programs in U.S. AMA 35

39 Table 9 illustrates the pool from which residents/fellows are drawn which is also an important workforce consideration. Research from the CHWS, completed for the Task Force, found that 32 percent of the residents/fellows training in New Jersey come from U.S. medical schools, with only 12 percent graduating from an in-state school. As stated earlier, the majority of residents/fellows (59 percent) come from international schools. With respect to the specialty groups, the surgical specialties and subspecialties relied most heavily on physicians from medical schools outside the state, with more than half of the residents/fellows in those programs having attended a medical school outside New Jersey. The exception is urology that had 56 percent in-state physicians. The hospital-based specialties consistently had the greatest concentration of residents/fellows from New Jersey medical schools. The primary care specialties were most reliant on IMGs with 74 percent of residents/fellows having attended a medical school outside the U.S. and Canada. Specialties TABLE 9: Origins of Physicians Training in New Jersey, 2006/07 Specialties in red may currently be in short supply Primary Care Specialties In-State* Out-of- State* International Canada Osteopathic Family Medicine 9% 8% 73% 0% 9% Internal Medicine 6% 9% 80% 0% 6% Pediatrics 8% 12% 64% 0% 16% Geriatrics 0% 0% 100% 0% 0% Obstetrics and Gynecology 9% 15% 64% 0% 12% Primary Care- Related Specialties General Surgery 16% 44% 37% 0% 2% Hospitalbased Specialties Surgical Specialties and Subspecialties Anesthesiology 18% 25% 45% 0% 12% Emergency Medicine 22% 49% 10% 0% 18% Pathology - Anatomic and Clinical 10% 3% 88% 0% 0% Radiology - Diagnostic 31% 58% 7% 0% 4% Colon and Rectal Surgery 0% 100% 0% 0% 0% Neurological Surgery 11% 89% 0% 0% 0% Ophthalmology 40% 47% 13% 0% 0% Orthopedic Surgery 22% 70% 6% 0% 1% Otolaryngology 10% 90% 0% 0% 0% Plastic Surgery 33% 50% 17% 0% 0% Thoracic Surgery 0% 100% 0% 0% 0% Urology 56% 38% 6% 0% 0% Surgical Subspecialties 0% 42% 42% 8% 8% Internal Medicine Subspecialties 15% 16% 56% 1% 12% Pediatric Subspecialties 0% 7% 79% 7% 7% Combined Specialties 26% 17% 39% 4% 13% Other Specialties and Subspecialties Allergy and Immunology 0% 50% 50% 0% 0% Dermatology 50% 42% 8% 2% 0% Neurology 3% 3% 83% 0% 10% Physical Medicine and Rehabilitation 42% 39% 0% 0% 18% Preventive Medicine 0% 33% 67% 0% 0% Psychiatry 15% 7% 64% 0% 13% Total 12% 20% 59% 0% 9% *In-State and Out-of-State refer to allopathic schools only. Sources: State-level Data for Accredited GME programs in the U.S., 2006/07. AMA 36

40 RETENTION Case studies presented by Jefferson Medical College in Pennsylvania and the Georgia Board for Physician Workforce, along with numerous publications, suggest that birth place and growing up in the same state are strong predictors of a student staying in-state to establish clinical practice. These predictors become increasingly stronger if the person stays in-state for medical school and then for residency. In rural physician studies, which are largely applicable to primary care, the literature has repeatedly and consistently documented that rural-raised individuals are more likely to return to their rural roots and establish practices in underserved, rural areas. Additionally, pairing rural-raised individuals with mentoring in the value of family medicine has a cumulative effect. 34 Students enrolled in Jefferson s Physician Shortage Area Program, who are selected for their intent on becoming a family physician, as well as for their background in a small town or rural area, are eight times more likely than their peers to become rural family physicians, two times more likely to specialize in internal medicine/pediatrics, and twenty percent more likely to become rural non-primary care physicians. Annually, between 800 and 850 physicians complete GME in New Jersey. Of these physicians, nearly 60 percent leave the state. Those physicians seeking additional training after completing a residency or fellowship training program in New Jersey are more likely to leave the state than those entering patient care or clinical practice upon completion of their training. According to a 2009 resident exit survey conducted by the Council, only 29 percent of respondents had future plans to stay in New Jersey after training while 62 percent were leaving the state or country, and 9 percent did not know their next location. Of the resident/fellows headed for additional training/fellowship in another state, only 12 percent responded that they planned to return to New Jersey later to establish a practice. For the residents/fellows entering clinical practice outside New Jersey (65 percent), the key factors in leaving the state were proximity to family, better job opportunities in other states, and the sense that better salary/compensation existed outside New Jersey. Lastly, the survey showed that residents and fellows who grew up in New Jersey and trained in New Jersey were by far the most likely to stay in New Jersey. Fewer than half of new physicians are staying in New Jersey after completing training New Jersey natives who attended an in-state medical school are the most likely to report plans to practice in New Jersey after completing GME training Proximity to family and better job/practice opportunities were the top two reasons citied by new physicians for planning to practice outside New Jersey 2009 Resident Exit Survey (NJCTH) Table 10 illustrates how retention rates in New Jersey, as reported by the AAMC, compare to the Middle Atlantic division and the U.S. There appears to be a link between the amount of education/training a physician receives in a state and the likelihood of him/her staying to practice in a state. Thus, recruiting and retaining state residents into New Jersey s medical education pipeline looks to be a worthwhile investment. TABLE 10: Comparison of Retention Rates in Surrounding States Physicians who graduated UME in the state and are active in the state Physicians who graduated GME in the state and are active in the state Physicians who graduated UME and GME in the state and are active in the state NJ NY PA US Benchmark 35.3% 36.5% 34.8% 38.8% 62.4% (CA) 46.9% 46.4% 42.1% 47.2% 69.8% (AK) 64.4% 58.2% 58.6% 66.0% 83.5% (HI) SOURCE: 2007 State Physician Workforce Data Book, AAMC. 37

41 In New Jersey, low numbers of residents/fellows in the shortage specialties (e.g., family medicine, obstetrics and gynecology, and pediatric subspecialties) graduated from in-state medical schools (Table 9). Workforce retention and recruitment strategies should aim to reverse this trend. Other Factors impacting Physician Supply Beyond current and future supply/demand scenarios, the Task Force considered other factors known to influence physician decision-making regarding specialization (i.e., primary care versus specialty) practice, the pursuit of further training post-residency, or practice location. Current physicians in training have a very different mindset compared to physicians who graduated 20 years ago. The friendliness of the practice environment as well as the balance between their professional career and personal lives greatly impact decision-making. Unfortunately, New Jersey is considered to have a hostile practice environment due to several key factors, including; under-compensation, over-regulations, unwillingness to address medical malpractice crisis in a more substantive way and few opportunities for practice in large single specialty or multi-specialty group practices. Lifestyle Choices In its 2008 Survey of Final Year Medical Residents, Merritt Hawkins & Associates found that geographic location/lifestyle was the most important consideration in identifying practice opportunities (Table 11). Other studies 35,36 have also found lifestyle to be a key factor in the career decisions of medical students, who are increasingly drawn toward specialties with controllable lifestyles. A controllable lifestyle, defined as having more personal time and greater control of hours spent on professional duties, seems to be drawing medical students towards residency programs in radiology and anesthesiology, and away from programs in general surgery, family practice, and internal medicine. Undoubtedly, this trend will alter the composition of the physician workforce, leading to an increased supply of physicians in specialties with controllable lifestyles and a decreased supply in uncontrollable specialties. Table 11: Controllable vs. Uncontrollable Lifestyle Specialties Specialties with perceived controllable lifestyle Anesthesiology Dermatology Emergency Medicine Neurology Ophthalmology Otolaryngology Pathology Psychiatry Radiology Specialties with perceived uncontrollable lifestyle Family Practice Internal Medicine Obstetrics/Gynecology Orthopedic Surgery Pediatrics Surgery (general) Urology Medical Malpractice Of respondents who indicated in the Council s 2009 resident exit survey that they were going to practice outside New Jersey, not one indicated the cost of malpractice insurance as a main reason for leaving the state. Nonetheless, New Jersey is one of several states that is listed as having a medical malpractice liability crisis by the AMA, whose main determining factor is the degree to which patients are losing access to care followed by the affordability/availability of professional liability insurance; severity of jury awards and settlements; and a state s legislative, legal, and judicial climates. A variety of tort reforms have been tested by states, including limits to non-economic damages, expert witness standards, apology statements, greater insurance 38

42 company accountability, and litigation alternatives. The malpractice crises have caused physicians to reduce their scope of practice, leave states, or choose early retirement; and could clearly limit physician supply in the hardest hit specialties (e.g., obstetrics and gynecology, surgery, orthopedic surgery, radiology, neurology, and emergency medicine). Alternatively, while the impact of a friendlier malpractice climate is hotly debated, historical trends demonstrate that states passing laws to protect physicians from large malpractice awards are better able to attract and retain physicians. In 2008, New Jersey s Medical Malpractice Liability Insurance Premium Assistance Fund provided more than $16 million in financial aid to nearly 1,200 obstetricians, neurosurgeons, and radiologists 37. Practice Setting According to Merritt Hawkins & Associates, physician recruits seem to be most interested in practicing in an employed setting with either a medical group or a hospital (Table 12). Only 1 percent of residents are open to solo practice, which is down from 8 percent in Similar results were found in another study 38 that indicated residents seek settings where they can concentrate on their specialty area of practice, like hospitals or single specialty practices. Likewise, the Council s 2009 Resident Exit Survey indicated that 80 percent of respondents going into patient care were headed into a group practice or hospital setting, and a majority (65 percent) were going to be employees in their upcoming practice, rather than partners and/or owners. In terms of recruitment and retention, New Jersey s preponderance of one and two physician practices is a disincentive for most new physicians. Ideal Practice Settings Table 12: Ideal Practice Settings Partnership 24% Single Specialty Group 23% Hospital Employee 22% Multi-Specialty Group 16% Outpatient Clinic 8% Association 4% Unsure 1% Solo 1% HMO 1% Locum Tenens 0% Source: 2008 Survey of Final Year Medical Residents. Merritt Hawkins & Associates. Student Debt After geographic/lifestyle considerations, a strong competitive financial package and loan forgiveness were the top factors that medical residents looked for in a practice according to a national survey (Table 13). Increased debt seems to correlate with specialty choice, having a negative impact on medical residents choosing less lucrative primary care specialties like family practice. The average graduating medical school debt has risen faster than the consumer price index for the past 20 years, and seems to be increasing more rapidly than physician incomes. According to the AAMC, the median debt of a public medical school graduate was $120,000 in 2006, a 6.9 percent increase over the previous year. The median debt for private school graduates was $160,000 (or a 5.9 percent increase). Moreover, the percentage of students in 39

43 debt at graduation has grown to 86 percent for public medical school graduates and 85 percent for private school graduates 39. Projections for the debt of both public and private medical school graduates are about $750,000 by According to AAMC, the 2008/09 tuition for New Jersey medical schools is $25,218 and $39,461 for residents and nonresidents, respectively. This is a 9 percent increase from the previous year and a 63 percent increase from ten years ago. However, despite rising tuition, the Council s 2009 resident exit survey showed that about 58 percent of New Jersey s residents and fellows have a current educational debt level of less than $100,000, with 37 percent having no debt at all. Moreover, an overwhelming majority (91%) of respondents indicated that they will not be participating in a loan forgiveness/repayment program. Table 13: Most Important Factors When Considering Practice Opportunities Most Important Factors When Considering Practice Opportunities Most Important Geographic location/lifestyle 57% Good financial package 46% Educational loan forgiveness 42% Low malpractice area 33% Proximity to family 30% Adequate call/coverage/personal time 28% Good medical facilities/equipment 23% Specialty support 17% Source: 2008 Survey of Final Year Medical Residents. Merritt Hawkins & Associates. Reimbursement Rates Physician reimbursement rates vary widely by specialty and state, and are based on a number of factors such as geography, work requirements, practice expense, and malpractice expense. As one would expect, payments from government reimbursement programs factor into whether a state is considered to have a practice environment that recognizes the value of physicians and supports, through these state driven reimbursement rates, the success of a medical practice. A review of 2007 Medicare data showed that New Jersey received about $10,567 per person served by Medicare, which was well above the U.S. amount of $8,921 per person. With respect to Medicaid, New Jersey does not fare well. Average physician fees in 2008 were only 58 percent of the national average, the lowest of all states, and were only 37 percent of Medicare payments. In primary care and obstetrics, New Jersey s average Medicaid fees were only 69 percent and 37 percent of the national average, respectfully. Lastly, a GAO study 40 that looked at physician prices paid by the Federal Employees Health Benefit Program ranked all of New Jersey s metropolitan areas in the lowest quartile. The impact of low reimbursement rates on physician workforce is unclear, but it certainly could be an obstacle to physician recruitment and retention. 40

44 Section Three A Summary of New Jersey s Current Physician Supply 41

45 Section Three A Summary of New Jersey s Current Physician Supply Despite the inherit difficulties in determining the adequacy of a physician workforce, the Task Force believed it was important to compile a list of specialties where current supply seemed insufficient in New Jersey. Using available, albeit imperfect data, the Task Force synthesized a variety of workforce information, benchmarking studies (both internal and external), as well as the perceptions of its membership, and concluded that statewide shortages may currently exist in: dermatology, emergency medicine, family medicine, geriatric medicine, neurological surgery, obstetrics, and numerous pediatric subspecialties. Furthermore, information suggests that there could be regional shortages in general surgery, hematology/oncology, and neurology. As mentioned, it is the group s perception that obstetrics is a shortage specialty in New Jersey, probably due to rising medical malpractice premiums, possibly masked by the fact that, in most data collection, obstetrics and gynecology are combined. There was also consensus that New Jersey residents are having trouble getting appointments with psychiatrists, and that more investigation will be needed to determine across all specialties whether low supply or limited insurance participation is to blame. Based on the physician-to-population benchmarks, the supply baseline forecasting model was rerun to integrate current shortages into the baseline assumptions, for both family medicine and the numerous pediatric sub-specialists. Likely Shortage Specialties Currently in New Jersey Dermatology Emergency Medicine Family Medicine General Surgery* Geriatric Medicine Hematology/Oncology* Neurological Surgery Neurology* Obstetrics Numerous Pediatric Subspecialties *Information suggests that these shortages may be regional and not statewide 42

46 Section Four Future Physician Need in New Jersey 43

47 Section Four Future Physician Need in New Jersey There is no single accepted approach to estimating physician supply and demand. Varying assumptions related to factors that may affect future supply or demand can lead to different conclusions about the adequacy of future physician supply (GAO, 2003). A key activity of the Task Force was to validate sources of data and review forecasting projections which profiled the various future physician supply and demand scenarios for New Jersey s workforce. In this section, supply and demand forecasts are projected for the years between 2008 to 2020, and are broken out by physician specialty, as well as region (Northern and Southern New Jersey). The CHWS played a pivotal role in this endeavor, and helped the Task Force understand factors that influence the supply/demand of physician services. Additionally, the CHWS assisted the group in framing New Jersey s most likely demand scenario which quantified factors such as universal health care, economics, and efficiency. The Task Force also weighted the potential impact of the new Obama administration, the success of the stimulus package, and how the national health system reform will influence physician demand. Depending on the breadth and speed of change, the projection of physician supply and demand needs will change in New Jersey. Thus, the Task Force established Goal #1 (establish a central entity within the state) to continually analyze the workforce data, manage and build consensus regarding workforce needs, and refine policy strategies to ensure New Jersey citizens have access to needed physicians. PROJECTED SUPPLY Methodology There are many factors to consider when forecasting physician supply and demand in a particular geography. These include (but are not limited to) the size and characteristics of the current physician supply and of new physicians entering the workforce; how physician services are utilized in terms of the characteristics of patients, the location where they are provided, and who provides them; and the characteristics of the population in the particular area. Also important are potential medical advances, physician practice and migration patterns, public and private health care cost-containment efforts, changes in the health care delivery system and health insurance coverage, and a host of other related factors. The supply forecasting model, developed and maintained by the Lewin Group, was used to forecast the future supply of physicians in New Jersey. 41 It considered the following supply determinants: The overall number and composition (gender, age, year of medical school graduation, location of medical school, and practice activity) of the current supply of active physicians in New Jersey; The overall number and composition of new entrants into the physician workforce by source (allopathic, osteopathic, US medical graduates, and IMGs); Retirement, death, and other rates of separation from physician workforce; and Rates of physician migration into and out of the state. 44

48 New Jersey s current baseline supply totals 23,748 licensed physicians. As discussed, the AMA Physician Masterfile was scrubbed with Board of Medical Examiners licensure data to determine the actual number of post-residency, patient care physicians which totals about 22,410 physicians (8,233 primary care physicians and 14,177 specialists), approximately 94 percent of the licensed physicians (Table 13a). Again, this number excludes physicians in non-patient care settings who perform research and administration, as well as physicians in training (residents/fellows). The baseline supply scenario assumed that the physician production, practice patterns, rates of separation from the workforce, and migration patterns would remain constant over time over the forecast period. Moreover, to forecast regional differences, it was assumed that new physicians would distribute themselves into the northern and southern regions as currently occur. Table 13a: Adjusted Physician Supply Unadjusted Adjusted Current Baseline Physician Supply (2008) Projected Baseline Physician Supply (2020) 23,748 22,410 Includes non-clinical physicians and physicians-in-training Includes only post-residency, patient care physicians, which is about 94% of all licensed physicians 26,274 24,697 Assumes all variables remain constant over time and does not account for current shortages/surpluses Accounts for surpluses/shortages that likely exist in some specialty areas Projected Baseline Physician Supply: New Jersey s 2020 baseline supply forecast is 26,274. Since this amount assumes all variables remain constant, the Task Force asked CHWS to perform a quick (and somewhat rudimentary) recalculation to account for current surpluses/shortages that likely exist in some specialty areas. The adjusted 2020 baseline supply projection was 24,697 (Table 13a). While 26,274 is the figure used in the forecasting model, the revised projection (24,697) was used to develop the Most Likely Demand Scenario that appears later in this section (Tables 1 and 14). Between 2008 and 2020, the baseline forecast suggests the physician supply in New Jersey will grow by almost 11 percent. In Northern New Jersey, the growth will be 10 percent, while the growth in Southern New Jersey will be 12 percent. Over the same period, the New Jersey Department of Labor forecasts that the state population will grow by 9 percent, with 8 percent growth in Northern New Jersey and 11 percent growth in Southern New Jersey. Figure 7: Active Physician Supply Baseline Forecast: NJ North South 30,000 20,000 10, NJ 23,748 24,331 25,544 26,274 North 18,101 18,522 19,403 19,939 South 5,647 5,809 6,142 6,335 Note: Amounts include physicians providing clinical care, physicians in non-clinical positions and physicians-intraining. When adjusted to include only post-residency, patient care physicians, the 2008 supply equals 22,410. Adjusting for current surpluses/shortages, the 2020 supply equals 24,

49 Between 2008 and 2020, the baseline forecast suggests that the primary care physician supply in New Jersey will grow by almost 11 percent. In Northern New Jersey, the growth will be 11 percent, while the growth in Southern New Jersey will be about 12 percent. The supply of nonprimary care physicians is forecast to increase by 11 percent statewide, 10 percent in Northern New Jersey, and 13 percent in Southern New Jersey. Primary Care 20,000 15,000 10,000 5,000 Figure 8: Active Physician Supply Baseline Forecast: New Jersey Northern NJ Southern NJ 15,086 15,453 Non-Primary Care 16,212 16,678 8,662 8,878 9,333 9,596 Primary Care 16,000 12,000 8,000 4,000 11,500 11,759 Non-Primary Care 12,301 12,644 6,601 6,762 7,102 7,295 Primary Care 5,000 4,000 3,000 2,000 1,000 3,586 3,694 Non-Primary Care 3,911 4,034 2,061 2,116 2,231 2, PROJECTED DEMAND Methodology A demand forecasting model, maintained by the Altarum Institute, was used to forecast the future demand for physicians in New Jersey, considered the following demand determinants: (1) physician utilization rates by age, gender, practice setting, insurance status, location of service (rural and urban), and physician specialty; and (2) size and composition (age, gender, insurance status, and location) of population in the state. Specifically, the Task Force considered a number of different physician demand scenarios in New Jersey by specialties and regions, created by the CHWS, and then integrated them to define the Most Likely Demand Scenario from 2008 to 2020, weighing the following factors, Expansion of health insurance coverage for children and adults; Changes in utilization of physician services; Annual economic growth in New Jersey; and Efficiency improvements in the delivery of physician services, such as IT innovations, electronic health records, and adoption of best practices. FIGURE 9: Selected Assumptions of the Most Likely Demand Scenario Everything stays the same Baseline Universal Health for Children Universal Health for Adults Economic Growth More Efficient Services reduced duplication/ excess utilization Nothing new Nothing Nothing Gradual Major new new reform change 250K Children uninsured 1,150,000 Adults uninsured 175K more kids insured 345K more insured 25K more kids insured 115K more insured 25K more kids insured 115K more insured 25K more kids insured 115K more insured % 1% 1.5% 1.5% 1.5% 2.0% 2.0% 2.0% 2.5% 2.5% 100 % 100% 345K remain uninsured 46

50 Projected Physician Demand: Under the Most Likely Demand Scenario, the physician demand was forecast to grow at a rate of 1.5 percent annually over the forecast period. Demand for physicians in New Jersey in 2020 was forecast to be greater than 28,000, an increase of 19.9 percent compared to demand for physicians in Demand for non-primary care physicians was forecast to increase at a slightly greater rate than demand for primary care (1.6 percent compared to 1.4 percent annually). Demand for cardiovascular disease specialists and urologists were forecast to grow at the fastest rate of 2.0 percent annually, in large part due to the rapidly growing baby boomer generation. The slowest demand growth was forecast for emergency medicine, obstetrics/gynecology, and general pediatrics (0.4 percent, 1.0 percent, and 1.0 percent annually, respectively. Figure 10. Demand for Physicians in New Jersey, ,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 New Jersey Total Northern New Jersey Southern New Jersey Primary Care 10,251 7,791 2,459 Non-Primary Care 18,215 13,840 4,375 Factors not considered in the most likely demand scenario include the impact of Washington D.C. s success in initiating significant health reform and increasing the number of citizens who have health insurance. These reforms raise several questions. Will newly insured individuals create substantial new demand for physician services? Will the proposed nationwide IT integration, the establishment of an Electronic Medical Record and other health system reforms substantially increase efficiency? Will improved efficiency partially offset new demand for physician services created by the newly insured? Other uncertainties include the new care models that are emerging, such as the Patient Centered Medical Home Model (PCMH), recently endorsed by the American Medical Association and recommended by the New Jersey Health Care Access Study Commission to be studied as a way to provide medical services at lower costs to a larger segment of the population (Appendix 6). The PCMH is an approach to providing comprehensive primary care that facilitates partnerships between individual patients and their personal physicians, and with the patient s family when appropriate. It is based on proactive coordination of care and a continuous relationship with a health care provider (or team of providers) to help patients navigate the health care system. Vital elements of PCMH include: whether physicians work closely with other providers in patient care teams; how well care is coordinated and integrated; whether care is delivered in ways that maximize quality and safety; and whether patients can reach physicians by or other nontraditional ways. If PCMH becomes commonplace, demand for primary care providers may increase and demand for some specialists could decrease. While there is some concern over the nature and degree of overlap with physician services, non-physician clinicians (NPCs) are widely accepted and their services are well-documented as high in efficiency and quality. AAMC 42 recently modeled two hypothetical scenarios to gauge 47

51 the impact on physician demand if physician assistants (Pas) and nurse practitioners (NPs) provide a greater proportion of health care services, or if they increase physician productivity. In the first scenario it was assumed that PA and NP supply grows annually by 2 percent between 2006 and 2025 and that each additional two PAs or NPs reduces physician demand by one. Physician supply was projected to grow to 843,800 by 2025 (or 15,500 fewer FTE physicians than predicted under the baseline scenario). In the second scenario, a gradual shift toward greater PA and NP roles in providing primary care services leads to the nation requiring 25 percent fewer primary care physicians in 2025 than are projected in the baseline scenario (or 75,100 fewer FTE physicians). An increased role for NPs in the provision of care seems like a key component in the overall solution to physician shortages. Despite these unknowns, the Task Force determined the factors outlined in the most likely demand scenario were as targeted as possible. The next step in the forecasting process was to model several supply scenarios with the projected demand forecast. These supply scenarios included: Supply Scenario 1 (Baseline): This scenario assumed the physician production, practice patterns, rates of separation from the workforce, and migration patterns would remain constant over the 2008 to 2020 forecasting period. Supply Scenario 2 (Increased retention of physicians trained in New Jersey): This scenario assumed there would be an increase in retention of physician trained in the state by 25 percent. Supply Scenario 3 (Increased graduate medical training in New Jersey): This scenario assumed the number of resident/fellow training positions would increase by 10 percent, 20 percent, and 30 percent. It also assumed the current in-state retention rate for residents and fellows remained the same. Supply Scenario 4 (Change in retirement behavior of physicians in New Jersey): This scenario assumed changes in the timing of when New Jersey physicians retire. Currently the median age of physician retirement in the U.S. is 66. By analyzing the results of these numerous supply scenarios the Task Force was able to determine the most likely physician workforce shortage by 2020, outlined in Table 14. As important, the Task Force was able to identify goals, recommended programs, action steps and related metrics to address the current and future shortages in both primary care and specialists. SUPPLY/DEMAND GAPS New Jersey, like many states, is facing current and future shortages in primary care and certain specialty physicians. The table below details the findings: 48

52 Table 14: Most Likely Demand Scenario Baseline Supply: Physician production, practice patterns, rates of separation from workforce, and migration patterns remain constant 2008 Current Supply* Projected Projected Shortage Baseline By 2020*** Supply By 2020** TOTAL PRIMARY CARE SPECIALISTS 22,410 8,233 14,177 24,697 9,020 15, , ,219-2,835-1,006-1,829 Anesthesiology 1,406 1, Cardiovascular Diseases 1,013 1, Emergency Medicine General Internal Medicine 3,825 4, General Pediatrics 2,539 2, General Surgery General/Family Medicine 1,869 2, Obstetrics & Gynecology 1,353 1, Ophthalmology Orthopedic Surgery Other Int. Med. Subspecialties 2,007 3, Pediatric Subspecialties **** Other Specialties 1,170 1, Other Surgical Specialties Otolaryngology Pathology Psychiatry 1,302 1, Radiology 961 1, Urology * Amounts include only post-residency, patient care physicians, which is about 94% of all licensed physicians (23,748). ** Amounts for Total, Primary Care, and Specialists were adjusted to take into account surpluses/shortages that are believed to currently exist in some specialty areas. The unadjusted baseline supply for 2020 is 26,274 (9,596 primary care; 16,678 non-primary care). *** The projected shortages are based on adjusted 2020 Projected Baseline Supply. **** Pediatric Subspecialists supply and demand data can be found on Appendix 10. INSIGHTS REGARDING FUTURE PHYSICIAN SUPPLY The Task Force concluded that, at present, the top three specialties with the greatest unmet need were family medicine, numerous pediatric sub-specialists, and obstetrics. This problem was demonstrated through the Most Likely Demand Model to grow worse in the future due to New Jersey s smaller than average physician pipeline, the state s aggressive actions to enact universal health care for children and adults, the lower than average in-state retention of physicians post graduation in establishing their clinical practice or pursuing additional training in New Jersey, and numerous other factors. By 2020, the supply and demand model documented the need for over 2,800 additional physicians, a 12 percent gap in the physician supply versus the likely population demand for services. There is a need for almost 1,000 primary care physicians and 1,800 specialists above the current capacity of New Jersey s medical school and GME production pipeline. The specialties forecast to experience the greatest shortages (greater than 100 physicians) were as follows: 49

53 Primary Care Family Medicine General Internal Medicine Specialists Anesthesiology Cardiovascular Disease General Surgery Orthopedic Surgery Pediatric Sub-specialists Radiology As the Task Force weighed the magnitude of these numbers, it was determined that a multifaceted strategy would need to be deployed to address this problem. To put the task into perspective: 400+ additional family medicine physicians are needed by 2020 to provide adequate primary care access for New Jersey citizens. If the Task Force only focused on adding resident slots to accomplish this goal, over 130 new family medicine resident slots would have to be in place and filled next year (2010) to meet that objective. Obviously this is impossible using just one strategy. 50

54 Section Five Recommendations 51

55 Section Five Recommendations Task Force s Review of Existing Programs Over the past fourteen months the Task Force heard numerous presentations and reviewed materials that overviewed New Jersey s existing programs. It is the Task Force s belief that the Recommendations and Action Steps, outlined in the following section, should build upon existing programs. Table 15 overviews current healthcare workforce programs. New Jersey Program Advisory Graduate Medical Education Council (AGMEC) J-1 Visa Waiver/ Conrad State 30 Program Medical Malpractice Liability Insurance Premium Assistance Fund National Health Services Corps (NHSC) Physician Workforce Policy Task Force Primary Care Loan Redemption Program (LRP) Touro University College of Medicine (LCME Candidate School) Table 15: Current Workforce Activities in New Jersey Description AGMEC was established through legislation and subsequent statute, to make recommendations for the support of GME programs, for the development and implementation of new GME programs that meet state needs and track federal, state and private funding. Additionally, AGMEC responsibilities include obtaining and evaluating information concerning the state s graduate medical manpower needs and determining the number/type of GME programs that should be supported in particular hospitals in relation to state needs. During Governor Whitman s tenure, funding was eliminated. At this time, AGMEC meets on an ad hoc basis to address physician training issues, currently the off-shore clerkships. There is no budget, staff, or facilities A state-sponsored structure for administration of the federally-authorized J-1 Visa Waiver Program that aims to address chronic physician shortages (mainly of primary care and mental health clinicians) by granting J-1 Visa waivers that extend the stay of foreign clinicians. Instead of returning to their home country for at least two years after training, clinicians with a waiver can remain in the U.S. if they agree to practice in HPSA-designated underserved areas. A fund providing direct relief towards the payment of medical malpractice liability insurance premiums for certain health care providers in New Jersey (currently, OB/GYN, neurosurgery, and diagnostic radiology), who in return agree to practice in the state for two years. A federal initiative, similar to the LRP, where scholars (physicians or mid-level practitioners) are selected to provide primary care in HPSAs in exchange for tuition, fees, and other reasonable expenses. A temporary initiative, formed in 2007 by the New Jersey Council of Teaching Hospitals, to analyze state-specific physician workforce data, as well as formulate policy, and eventually a state plan for addressing physician shortfalls An initiative where certain primary care providers (physicians, PAs, NPs, certified nurse midwives, dentists) are eligible to redeem up to $120,000, over four years, of loans used to finance their medical education in exchange for 2 years of full-time practice in medically underserved communities throughout New Jersey. The LRP has developed its own index of medical scarcity that is independent of federal determinations of primary care need. Each year, the Office of Primary Care (with the Commissioner of Health and Senior Services approval) identifies provider shortage areas, or communities that are medically underserved (i.e., have the poorest health status and economic indicators). See Appendix 7. Touro University College of Medicine is a new allopathic medical school that was founded in It will start with a class of 40 in August 2010 (pending accreditation), expanding over time to students. 52

56 The Task Force s Recommendations Goal I - Create or designate an organization, the Center for Medical and Health Workforce Planning, to continuously monitor, forecast, predict, and refine recommendations to ensure an adequate and welldispersed supply of physicians and advanced practice practitioners for New Jersey. The Center will be responsible to perform (or subcontract with an entity to perform) the collection, analysis of multiple data sources, and comprehensive reporting on health workforce supply and demand trends. With this information the Center will guide the allocation of resources based on workforce needs, track physician and advanced practice provider shortages to determine GME and other funding priorities, manage vacant resident positions, direct funds to the individual programs with greatest impact on workforce needs, and provide incentives for teaching programs to retain graduates to practice in New Jersey. (Organizational models for Georgia s Board for Physician Workforce and Utah s Medical Education Council can be seen under Appendix 9). Establish the infrastructure, professional personnel and necessary resources to facilitate the operations of the Center for Medical and Health Workforce Planning. Establish overall statewide policies and procedures for physicians and advanced practice providers to reinforce and direct workforce planning. Establish a New Jersey Office of Recruitment within the Center for Medical and Health Workforce Planning. Create a process to gather and maintain adequate data to guide interventions and policy recommendations. Implement policies and programs to ensure the diversity of the physician workforce supports the ethnic and cultural demographics within New Jersey. Interface with the National Health Workforce Advisory Council to submit data and obtain federal grants that will support New Jersey s health workforce initiatives. Oversee data collection and annual reporting that updates the supply and distribution of the physician and advanced practice provider workforce, as well as the in-state retention rates. Mandate data collection through physician re-licensure surveys, consumer health attitude surveys, state epidemiology data, utilization by ethnicity, etc., to ensure comprehensive, credible data are available to analyze trends and refine Task Force recommendations. Ensure necessary data are collected and collated to increase the number of Health Professional Shortage Area (HPSA) designated underserved areas in New Jersey. Use data to expand the Conrad State 30 (J-1 Visa) Program and federal loan repayment funds. Improve data collection specific to IMGs by requiring respondents to identify citizenship status. Use a unique identifier, such as the DEA or NPI number, to provide better data and tracking of New Jersey physicians and residents within and outside of New Jersey (to support recruitment/retention initiatives). 53

57 Expand data sources through surveys, state, and private data sources to track: demographics, health attitude/utilization by ethnicity, practice patterns, practice components, medical school application data, graduate tracking, etc. Goal II Expand retention and recruitment initiatives to encourage physicians to enter, remain in, or return to practice in New Jersey. New Jersey is competing with forty-nine states to recruit new physicians as they address their state s physician workforce shortages. New Jersey must expand current workforce programs, improve New Jersey s practice environment, and establish financial incentives which offset cost-of-living and small business barriers inherent to the state to be competitive. Our goals must be to foster innovation within existing programs and make certain we maximize federal programs and funding to ensure New Jersey is a viable state to practice medicine. Expand the current loan redemption program to target specialties with the most significant shortages. State-only program expands beyond primary care to include specialties with significant projected shortages by 2020, including pediatric sub-specialties. Federal-state loan repayment program improve data collection and analysis to requalify for federal HPSA designation and improve federal funding for loan repayment. Work with federal legislators to update Section 332 of the Public Health Service Act recognizing New Jersey s unique demographics and underserved areas. Create a recruitment internet site run by the Office of Recruitment, under the Center for Medical and Health Workforce Planning (see Goal #3), to serve as a comprehensive resource center for job and resident/fellowship position opportunities. Identify residents leaving the state to pursue fellowship training and create a fellowship training fund to support their educational expenses, with the guarantee they will return to the state to establish clinical practice post graduation. Establish a three-year state tax forgiveness program, practice subsidy fund, and a mortgage assistance program for new physicians establishing clinical practice in New Jersey. Identify educational and professional incentives, such as IT technology grants. Target pre-med students to direct mindset towards specialties of greatest needs. Consider expanding pipeline programs (K-12) that motivate and prepare New Jersey residents for medical careers. Improve New Jersey s physician practice environment and job satisfaction by raising Medicaid reimbursement rates to nationally competitive levels; improving the insurance environment by enhancing transparency and consistency in insurers claims processing rules; and promoting a less malignant medical malpractice environment that results in sustained lowered premiums and the fairer administration of justice. Identify and secure research grant opportunities to enhance fellowships positions within the state. 54

58 Goal III Align goals and incentives between the medical education stakeholders: medical schools, teaching hospitals, and the State of New Jersey. Reforms should focus on establishing strategic planning processes between the state, teaching institutions, and medical education leadership. Using data from forecasting models and data driven reports created by the Center, all stakeholders should work to ensure the medical education system is maintained or supported, including its physician specialty training programs and residency counts, and is adjusted to address future physician workforce shortages by specialties, as well as collaborate on strategies to increase in-state retention. Identify, target, and enroll students in medical schools who will more likely practice in New Jersey. Establish incentive grants for medical schools and teaching hospitals that encourage them to retain graduates post graduation. Develop curriculum to reinforce team-based care models that will ultimately promote multi-disciplinary care processes and the medical home model. This curriculum will allow New Jersey to qualify for federal grants and potential resident cap expansion via the proposed health reform initiatives. Create an Office of Recruitment within the Center for Medical and Health Workforce Planning to promote the job, fellowship, and resident position opportunities for New Jersey graduates and out-of-state physician residents. This Office can also serve as a resource to identify partnerships between hospitals for new fellowships, research grant opportunities, etc. Goal IV Enhance state funding for medical education and post graduate physician residency programs. Graduate medical education in New Jersey cost $765 million in Of this, state Medicaid GME funding is only $60 million (including federal matching dollars). Medicare funds approximately $340 million, leaving the balance to be paid by hospitals from foundation funds and operational margins. This Goal focuses on identifying sources for adequate funding which will then allow New Jersey to be more competitive. New Jersey must attract more students by increasing medical school capacity, adequately fund graduate medical training positions, address student medical education debt levels through viable programs, and improve the practice environment to retain or attract physicians seeking to establish their practice in this state. Increase state funding for medical education. Increase Medicaid GME funding, maximizing upper payment limit (UPL) federal match, and tie increases to Task Force goals. Increase Medicaid fee-for-service and Medicaid HMO physician service payments to minimally 80 percent of Medicare payments. Establish the New Jersey Medical Education Foundation, funded from the Horizon BC/BS for-profit conversion (if the conversion proceeds), or other foundation grants, to create a financial infrastructure that provides on-going funding for the variety of initiatives outlined in the Task Force recommendations. 55

59 Establish a commercial insurer covered lives tax; direct funds to address physician shortages and support operational expenses of the Center for Medical and Health Workforce Planning. Direct a portion of the Board of Medical Examiner s licensure and re-licensure fees to fund the Center for Medical and Health Workforce Planning activities. Institute off-shore clerkship fees that will assist in the funding of the retention and recruitment programs outlined in Goal II. Ensure the State of New Jersey adopts a State Workforce Plan and identifies the entity to request grants and funding, to optimize the health and education programs and related recommendations and initiatives identified by the Task Force. Funding and grants will soon be available through the federal stimulus package. Goal V Pursue federal reforms to address systemic problems in GME funding mechanisms, administrative processes, and regulatory oversight. Medical education and health care workforce needs have changed over the past 15 years, while regulations and funding methodologies have not. For example, more training takes place in an outpatient setting; however Medicare GME reimbursement is primarily inpatient driven. As the training model changes, the reimbursement methodology must be reformed. Additionally, the system is over-complicated with costly rules and regulations that thwart logic and stifle innovation. GME resident expansion, administrative, and funding systems must be addressed as national health system reform is being contemplated in Washington, D.C. Integrate GME reform into current health care reform initiatives to ensure newly insured citizens have access to physicians. Preserve existing resident slots assigned within New Jersey when a teaching hospital closes. Remove regulatory and funding barriers that limit executing flexible GME training venues beyond traditional sites. Revise current administrative guidelines to ensure clear, consistent administrative requirements and auditing standards across and between all Medicare s Fiscal Intermediaries. The Centers for Medicare and Medicaid Services (CMS) will publish administrative requirements and auditing standards in advance of implementation. Auditing rules will not be applied retrospectively. Increase caps for GME positions for states who have documented a ten percent or greater shortage in their physician workforce by An increase in physician resident positions will be allowed within primary care residencies and other specialties where shortages have been identified by HRSA utilized forecasting models. Conclusion These goals and action steps require state and federal commitment, public and private partnerships, as well as significant political will and health leadership engagement, to address system improvements, identify funding sources, and establish recruitment and retention programs. Medical schools, teaching hospitals, academic medical centers, and state agencies must be willing to embrace change, reject traditional thinking and be willing to give and take in reform negotiations. If these parties are successful, we can be assured that New Jersey s future physician and health care workforce will be able to meet the clinical and health care needs for all New Jersey citizens. 56

60 End Notes 1 Testimony of Richard A. Cooper, M.D., before the U.S Senate Committee on Health, Education, Labor and Pensions Hearing on Delivery Reform: The Roles of Primary and Specialty Care in Innovative New Delivery Models. May 14, New Jersey Commission on Rationalizing Health Care Resources Final Report. January Commissioner s Prenatal Care Task Force. Report and Recommendations to Commissioner Heather Howard. July Brownlee S and Cantor JC. Availability of Physician Services in New Jersey: Rutgers Center for State Health Policy, May AMA Physician Masterfile (January 2007) as published in AAMC s 2007 State Physician Workforce Data Book. Active physicians are licensed by a state and work at least 20 hours per week. Physicians who are retired, semi-retired, temporarily not in practice, not active for other reasons, or who have not completed their GME are excluded. 6 Touro University College of Medicine in Hackensack, NJ, the fourth medical school in the state, has not graduated a class of physicians as of the writing of this report. 7 Rutgers CSHP. Availability of Physician Services in New Jersey. March Calman N. U.S. Policies to Address Physician Maldistribution. Prepared for International Health Workforce Conference HRSA designates HPSAs and MUAs/MUPs. HPSAs are shortages primary medical/dental/mental providers that may be geographic (county/service area), demographic (low income) or institutional (e.g. FQHC). MUAs/MUPs are areas/populations that have too few providers, high infant mortality, high poverty and/or high elderly population. 10 The Physicians Foundation. The Physicians Perspective: Medical Practice in October Hauer KE, et al. Factors Associated with Medical Students Career Choices Regarding Internal Medicine. JAMA. 2008; 300(10); The number of older adults (age 65+) is expected to double by 2030 to nearly 70 million. 13 IOM. Retooling for an Aging America: Building the Health Care Workforce (Fill rate data as of 12/31/06) 14 Unless otherwise specified, primary care in this report includes the specialties: family medicine, internal medicine, general pediatrics, and geriatric medicine. 15 AAMC State Physician Workforce Data Book. In this report, primary care includes these specialties: adolescent medicine, family medicine, general practice, geriatric medicine, internal medicine, internal medicine/pediatrics, and pediatrics. 16 NJAFP. Perspectives on Family Physician Workforce in New Jersey. Available at: Accessed May 19, Rutgers Center for State Health Policy. Availability of Physician Services in New Jersey: May AAFP. Family Physician Workforce Reform (as approved by the 2006 Congress of Delegates) Center for Health Workforce Studies of the University of Albany. New Jersey Medical Education and Training Profile. (Prepared for the New Jersey Council of Teaching Hospitals). May American Geriatrics Society. Geriatrics Workforce Policy Studies Center Geriatrician Shortage Projections. (Based on a ratio of 1 geriatrician per 700 people.) Accessed May New Jersey Primary Care Association. New Jersey s Federally Qualified Health Centers: Quick Facts Edition. 22 Cooper RA, et al. Perceptions of Medical School Deans and State Medical Society Executives About Physician Supply JAMA. 290(22); O Leary, K and Hollander, F. The Shortage of Pediatric Subspecialists. Children s Hospitals Today. Winter American Academy of Pediatrics, Division of Workforce and Medical Education. 25 U.S. Census Bureau. Public Education Finances April Weiner, J.P. Prepaid Group Practice Staffing and US Physician Supply: Lessons for Workforce Policy. Health Affairs Web Exclusive. February 4, 2004: Akl EA, et al. The United States Physician Workforce and International Medical Graduates: Trends and Characteristics. Society of General Internal Medicine. 2007;22: AMA Web site. Available at Accessed January Wozniak GD. Practice Location Choices of New International Medical Graduates. AMA (Policy Research Perspectives) New Jersey Council of Teaching Hospitals New Jersey Resident Exit Survey. 31 Center for Health Workforce Studies of the University of Albany. New Jersey Demographic, Economic, and Health Status Profile (prepared for the New Jersey Physician Workforce Policy Task Force). May Center for Health Workforce Studies of the University of Albany. New Jersey Medical Education and Training Profile. (Prepared for the New Jersey Council of Teaching Hospitals). May AAMC. Data Warehouse: Applicant Matriculant File as of 9/25/ Rabinowitz HK, et al. Demographic, educational, and economic factors related to recruitment and retention of physicians in rural Pennsylvania. J Rural Health. 1999; 15: Cullison S, et al. Medical School Admissions, Specialty Selection, and Distribution of Physicians. JAMA. 1976;235: Hauer KE, et al. Factors Associated with Medical Students Career Choices Regarding Internal Medicine. JAMA. 2008; 300(10); Torpy JM, et al. Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students. JAMA. 2003; 290(9); AAP News 2008;29; Maryland Hospital Association and Med Chi. Maryland Physician Workforce Study AAMC. Medical School Tuition and Young Physician Indebtedness. October GAO. Federal Employees Health Benefits Program: Competition and Other Factors Linked to Wide Variation in Health Care Prices. August This modeling program makes the assumption that the current supply of primary care and specialty physicians is adequate to meet current population health needs. Thus, the baseline supply scenario, on which all other supply scenarios are built, must be manually adjusted with specialties with known shortages. 42 AAMC. The Complexities of Physician Supply and Demand: Projections Through November

61 NEW JERSEY PHYSICIAN WORKFORCE TASK FORCE REPORT APPENDICES

62 NEW JERSEY PHYSICIAN WORKFORCE TASK FORCE REPORT APPENDIX APPENDIX 1 PAGE 1 ACRONYM AND ABBREVIATION GUIDE

63 Acronym & Abbreviation Guide AAFP: American Academy of Family Physicians AAMC: American Association of Medical Colleges ACGME: Accreditation Council for Graduate Medical Education AGMEC: Advisory Graduate Medical Education Council AGS: American Geriatrics Society AMA: American Medical Association APN: Advanced Practice Nurse CHWS: Center for Health Workforce Studies, University at Albany CSHP: Rutgers Center for State Health Policy COGME: Council on Graduate Medical Education DEA: Drug Enforcement Administration DHS: Department of Human Services DHSS: Department of Health and Senior Services DOBI: Department of Banking and Insurance FQHC: Federally Qualified Health Center FTE: Full Time Equivalent GAO: Government Accountability Office GME: Graduate Medical Education HPSA: Health Professional Shortage Area HRSA: Health Resources and Services Administration IMG: International Medical Graduate IOM: Institute of Medicine LRP: Loan Repayment Program MUA/MUP: Medically Underserved Areas/Populations NACHRI: National Association of Children s Hospitals and Related Institutions NHSC: National Health Services Corps NJAFP: New Jersey Academy of Family Physicians NJCTH: New Jersey Council of Teaching Hospitals NPC: Non-Physician Clinician OB/GYN: Obstetrics and Gynecology PA: Physician Assistant PCMH: Patient Centered Medical Home RN: Registered Nurse UME: Undergraduate Medical Education UMEC: Utah Medical Education Council USMG: U.S. Medical Graduate

64 NEW JERSEY PHYSICIAN WORKFORCE TASK FORCE REPORT APPENDIX APPENDIX 2 PAGE 1-5 PHYSICIAN MAPPING DOCUMENT

65 New Jersey Physician Workforce Lewin's Forecasting Model Groupings of Physician Specialties Specialty Mapping Detailed Specialty Name Anesthesiology Pain Management Pain Management (Physical Medicine & Rehabilitation) Cardiovascular Disease Emergency Medicine Internal Medicine/Emergency Medicine Medical Toxicology (Emergency Medicine) Pediatric Emergency Medicine (Emergency Medicine) Sports Medicine (Emergency Medicine) Internal Medicine Abdominal Surgery Colon & Rectal Surgery Craniofacial Surgery Dermatologic Surgery General Surgery Hand Surgery Hand Surgery (Surgery) Head & Neck Surgery Oral & Maxillofacial Surgery Pediatric Cardiothoracic Surgery Pediatric Surgery (Surgery) Surgical Oncology Transplant Surgery Trauma Surgery Vascular Surgery Family Practice Family Practice/Psychiatry General Practice Geriatric Medicine (Family Practice) Sports Medicine (Family Practice) Adolescent Medicine (Internal Medicine) Adolescent Medicine (Pediatrics) Allergy Allergy & Immunology Clinical and Laboratory Immunology ( Internal Medicine) Clinical and Laboratory Immunology (Pediatrics) Clinical Cardiac Electrophysiology Clinical Laboratory Immunology (Allergy & Immunology) Developmental-Behavioral Pediatrics Diabetes Endocrinology, Diabetes and Metabolism Gastroenterology Geriatric Medicine (Internal Medicine) Forecast Specialty Name Anesthesiology Anesthesiology Anesthesiology Cardiovascular Diseases Emergency Medicine Emergency Medicine Emergency Medicine Emergency Medicine Emergency Medicine General Internal Medicine General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General Surgery General/ Family Medicine General/ Family Medicine General/ Family Medicine General/ Family Medicine General/ Family Medicine Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Center for Health Workforce Studies University at Albany, SUNY March

66 New Jersey Physician Workforce Lewin's Forecasting Model Groupings of Physician Specialties Specialty Mapping Detailed Specialty Name Hematology (Internal Medicine) Hematology/Oncology Hepatology Hospitalist Immunology Infectious Disease Internal Medicine (Neurology) Internal Medicine (Preventive Medicine) Internal Medicine (Psychiatry) Internal Medicine/Family Practice Internal Medicine/Pediatrics Interventional Cardiology Medical Oncology Medical Toxicology (Pediatrics) Neonatal-Perinatal Medicine Nephrology Nutrition Pediatric Allergy Pediatric Anesthesiology (Anesthesiology) Pediatric Critical Care Medicine Pediatric Emergency Medicine (Pediatrics) Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology/Oncology Pediatric Infectious Disease Pediatric Nephrology Pediatric Psychiatry/Child Psychiatry Pediatric Pulmonology Pediatric Radiology Pediatric Rehabilitation Medicine Pediatric Rheumatology Pediatrics/Emergency Medicine Pulmonary Critical Care Medicine Pulmonary Disease Rheumatology Sports Medicine (Internal Medicine) Sports Medicine (Pediatrics) Gynecological Oncology Gynecology Maternal & Fetal Medicine Obstetrics Obstetrics & Gynecology Reproductive Endocrinology Ophthalmology Pediatric Ophthalmology Forecast Specialty Name Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Other Internal Medicine Subspecialties Obstetrics and Gynecology Obstetrics and Gynecology Obstetrics and Gynecology Obstetrics and Gynecology Obstetrics and Gynecology Obstetrics and Gynecology Ophthalomology Ophthalomology Center for Health Workforce Studies University at Albany, SUNY March

67 New Jersey Physician Workforce Lewin's Forecasting Model Groupings of Physician Specialties Specialty Mapping Detailed Specialty Name Adult Reconstructive Orthopedics Foot and Ankle, Orthopedics Hand Surgery (Orthopedic) Musculoskeletal Oncology Orthopedic Surgery Orthopedic Surgery of the Spine Orthopedic Trauma Pediatric Orthopedics Sports Medicine (Orthopedic Surgery) Addiction Medicine Aerospace Medicine Child and Adolescent Psychiatry Child Neurology Clinical and Laboratory Dermatological Immunology Clinical Biochemical Genetics Clinical Cytogenetics Clinical Genetics Clinical Molecular Genetics Clinical Neurophysiology Clinical Pharmacology Critical Care Medicine (Anesthesiology) Critical Care Medicine (Internal Medicine) Critical Care Medicine (Obstetrics & Gynecology) Dermatology Epidemiology General Preventive Medicine Legal Medicine Medical Genetics Medical Management Medical Toxicology (Preventive Medicine) Neurodevelopmental Disabilities (Psychiatry & Neurology) Neurology Nuclear Medicine Occupational Medicine Osteopathic Manipulative Medicine Other (i.e., a specialty other than those appearing above) Pain Medicine Palliative Medicine Pediatric Cardiology Pharmaceutical Medicine Phlebology Physical Medicine & Rehabilitation Procedural Dermatology Public Health and General Preventive Medicine Radiation Oncology Sleep Medicine Forecast Specialty Name Orthopedic Surgery Orthopedic Surgery Orthopedic Surgery Orthopedic Surgery Orthopedic Surgery Orthopedic Surgery Orthopedic Surgery Orthopedic Surgery Orthopedic Surgery Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Center for Health Workforce Studies University at Albany, SUNY March

68 New Jersey Physician Workforce Lewin's Forecasting Model Groupings of Physician Specialties Specialty Mapping Detailed Specialty Name Spinal Cord Injury Medicine Sports Medicine (Physical Medicine & Rehabilitation) Surgical Critical Care (Surgery) Undersea & Hyperbaric Medicine Unspecified Urgent Care Medicine Vascular Medicine Cosmetic Surgery Facial Plastic Surgery Hand Surgery (Plastic Surgery) Neurological Surgery Pediatric Surgery (Neurology) Plastic Surgery Thoracic Surgery Otolaryngology Otology/Neurotology Pediatric Otolaryngology Anatomic Pathology Anatomic/Clinical Pathology Blood Banking/Transfusion Medicine Chemical Pathology Clinical Pathology Cytopathology Dermatopathology Forensic Pathology Hematology (Pathology) Medical Microbiology Neuropathology Pediatric Pathology Selective Pathology Pediatrics Addiction Psychiatry Forensic Psychiatry Geriatic Psychiatry Psychiatry Psychiatry/Neurology Psychoanalysis Abdominal Radiology Diagnostic Radiology Musculoskeletal Radiology Neurology/DiagnosticRadiology/Neuroradiology Forecast Specialty Name Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Specialties Other Surgical Specialties Other Surgical Specialties Other Surgical Specialties Other Surgical Specialties Other Surgical Specialties Other Surgical Specialties Other Surgical Specialties Otolaryngology Otolaryngology Otolaryngology Pathology Pathology Pathology Pathology Pathology Pathology Pathology Pathology Pathology Pathology Pathology Pathology Pathology General Pediatrics Psychiatry Psychiatry Psychiatry Psychiatry Psychiatry Psychiatry Radiology Radiology Radiology Radiology Center for Health Workforce Studies University at Albany, SUNY March

69 New Jersey Physician Workforce Lewin's Forecasting Model Groupings of Physician Specialties Specialty Mapping Detailed Specialty Name Neuroradiology Nuclear Radiology Radiological Physics Radiology Vascular and Interventional Radiology Pediatric Urology Urology Forecast Specialty Name Radiology Radiology Radiology Radiology Radiology Urology Urology Center for Health Workforce Studies University at Albany, SUNY March

70 NEW JERSEY PHYSICIAN WORKFORCE TASK FORCE REPORT APPENDIX APPENDIX 3 PAGE 1-44 PHYSICIAN SUPPLY AND DISTRIBUTION IN NEW JERSEY, 2008 (PROVIDED BY CHWS)

71 Physician Supply and Distribution in New Jersey, 2008 October 2008 Center for Health Workforce Studies University at Albany, State University of New York

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