Outpatient and Primary Care Need Growing

Transcription

1 Doctor Shortage: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey

2 Key Findings Physician Need Member hospitals and health systems identified a need for 1,026 physicians across the state, excluding New York City. Of that need, 26% (266) is for primary care physicians. Seventy-six percent of respondents indicated that physicians are leaving their communities because of retirement. Eighty-seven percent indicated that their ability to recruit physicians was the same or worse since last year. Fifty-three percent of rural hospitals received a Doctors Across New York physician recruitment and retention award, compared to 17% of non-rural hospitals. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey

3 Implications of Physician Shortages Sixty-one percent of respondents indicated that there are times when their emergency room is not covered by certain specialties, requiring them to transfer patients elsewhere. Upstate (northwest from the Hudson Valley to Buffalo), that number jumps to 71%. Thirty-two percent reduced and/or eliminated services as a result of the physician shortage; at rural hospitals, 51% eliminated and/or reduced services. Primary Care Capacity Sixty-three percent of respondents indicated that they did not have sufficient primary care capacity to meet their patients needs. The vast majority (81%) plan to hire more primary care physicians, but 69% reported that they are having difficulty recruiting these doctors. Eighty percent are planning to hire more non-physician primary care clinicians. Sixty-two percent of respondents indicated that a number of their primary care clinics were Patient-Centered Medical Homes. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey

4 The Healthcare Association of New York State (HANYS) strongly advocates for increased funding for the Doctors Across New York (DANY) program to bring at least 250 new physicians to under-served areas every year. HANYS also advocates for more funding for the Primary Care Service Corps to incentivize nurse practitioners and physician assistants to practice in under-served parts of the state in exchange for loan repayment. To improve this program, we are seeking statutory changes to eliminate the competitive procurement process. In addition to more Medicare-funded residency slots, HANYS supports the creation of more residency opportunities in rural and small city hospitals to increase the number of physicians in training who may be interested in providing primary care in under-served upstate communities. This is one of the recommendations in the New York State Department of Health s (DOH) Health Innovation Plan and should be a state-funded initiative. HANYS supports the Area Health Education Centers and their ability to create a pipeline for prospective medical students who would be willing to work in rural and under-served areas. HANYS strongly advocates for the use of telehealth services, especially in rural areas where sub-specialists are hard to find, so that access to care can be improved for this population. To that end, we support legislation mandating reimbursement by all payers for telemedicine services. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey

5 Executive Summary In recent years, numerous published articles and studies have predicted that the shortage of primary care physicians will worsen as more people become insured through the Affordable Care Act (ACA). Several factors enter into these predictions, including the aging of the primary care workforce, diminishing numbers of new physicians who choose to practice primary care, combined with an aging population with multiple comorbidities and increased life expectancy. While United States medical schools have been steadily increasing their enrollment over the past few years to help address the shortages, the number of Medicare-funded residency slots has remained stagnant since Without an increase in the number of residency slots, fewer medical students will be able to find residency training upon graduation. To date, there has been little movement on legislation that would increase the number of residency slots funded by Medicare. In New York State, the focus has been on Medicaid redesign efforts, population health, and the Triple Aim of improving care outcomes, quality, and reducing costs. The ongoing establishment of Patient- Centered Medical Homes and Health Homes aims to improve access to primary care in New York State. However, this goal will be very difficult to achieve without an adequate number of primary care providers. HANYS members have made significant strides along the path to health care reform, but recruitment of certain types of physicians continues to be very challenging, which can impede progress. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 1

6 This report, which is based on the results of HANYS annual Physician Advocacy Survey, focuses on the physician climate in New York State, excluding New York City. Each annual edition of this report focuses on issues that directly impact hospitals and health systems ability to serve their communities. This year s survey, which covers the period from September 2012 to September 2013, focused on primary care and outpatient services as critical components of the new health care reform landscape. An outpatient program that provides timely access to care with a strong preventive service component, through a model that promotes care coordination with an interdisciplinary team focus on population health, is key to reducing hospital admissions and creating a healthier population. A total of 106 members completed the survey, for an overall response rate of 74% of hospitals and health systems outside of New York City. The results confirm the serious nature of the physician shortage, particularly for primary care. Since 86% of the state s rural hospitals also completed the survey, a separate section of this report is dedicated to rural hospitals and health systems. HANYS has issued this annual report since 2008 to educate policymakers and the health care community about the challenges facing hospitals and health systems. HANYS continues to be concerned about the lack of adequate funding for the Doctors Across New York (DANY) program, which has been highly successful in recruiting physicians to under-served communities. This survey was conducted by HANYS in HANYS advocates for a steady annual DANY funding stream that will collaboration with Western New York Healthcare support at least 250 new physicians each year, as well as additional Association, Rochester Regional Healthcare Association, Iroquois Healthcare Alliance, and funding for the Primary Care Services Corps program, which could Suburban Hospital Alliance of New York State. attract more nurse practitioners and physician assistants to primary care in under-served parts of the state. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 2

7 The Primary Care Workforce Shortage Our nation s hospitals are transforming care delivery to focus on improving the health of communities through preventive, patient-centered care, rather than emphasizing acute care. Improved technology and evidence-based care are leading to shorter hospital stays and more outpatient procedures at a reduced cost. A key goal is reducing unnecessary hospital readmissions. To accomplish this, most hospitals and health systems have increased their primary care, ambulatory care, and outpatient clinic presence in their communities, with a growing emphasis on preventive, team-based care. Two years ago, the American Hospital Association (AHA) convened a roundtable of clinicians and health experts to examine the future of primary care workforce needs. AHA Roundtable Recommendations: all health care professionals should be educated within the context of interdisciplinary clinical learning teams; primary care should be centered around the patient and family in a user-driven design; hospitals should evolve from traditional hospitals to health systems partnering with community organizations and patients to advance the community s wellness and health needs; hospitals can serve as catalysts for linking and integrating the various components of health care and wellness in a way that provides a sustainable infrastructure of health care for patients and the community; and a fundamental shift in reimbursement must occur to mitigate rising health costs. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 3

8 This proactive, coordinated approach to patient care makes sense, given the increase in the rates of many chronic diseases, the rise of value-based reimbursement, and emerging incentives to take responsibility for the health status of defined populations. Fully implementing new models of care requires an adequate number of primary care providers, particularly physicians. The shortage of primary care physicians has been cited in numerous articles and by many associations. In a November 2013 article in Modern Healthcare, Dr. Atul Grover, Chief Public Policy Officer, Association of American Medical Colleges (AAMC), stated that the U.S. would need to train an additional 4,000 doctors each year to avoid a shortage, with the expected ACA expansion of health coverage. While medical schools have been graduating record numbers of students and report increasing enrollment (6.1% increase at allopathic and 4.9% at osteopathic medical schools in the past year) the total resident workforce only grew 1.8% from the previous year. Federal legislation to increase the number of residency slots has not advanced in Congress and it appears unlikely that funding for Graduate Medical Education (GME) will be increased in the near term. Medicare now pays for less than 25% of direct training costs for residents and fellows. In another article, Dr. Grover noted that realistic workforce planning must take into account that expanded access to care, combined with an aging population with multiple comorbidities and longer life spans, will increase the use of health care per capita over the next few decades. 1 At the same time, the current physician population will drop as a result of an aging workforce. Thirty-three percent of current physicians are older than 55 and are expected to retire in the next decade. 1 Building a Health Care Workforce for the Future: More Physicians, professional reforms and technological advances, Health Affairs, November 2013, vol 32, no. 11, The Primary Care Workforce Shortage: Doctor Shortage: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey Page 4

9 A recent article in The Atlantic echoes a common theme, attributing the primary care shortage to low salaries for primary care physicians, combined with high debt from medical schools. 2 The author discusses the salaries for primary care physicians in countries across Europe, where pay gaps are far smaller between generalists and specialists, compared to the U.S. access to primary care is likely to improve the country s return on investment, Dr. Grover states that this will not result in a marked decrease in physician demand. Lower mortality, increased longevity, and greater lifetime utilization of health care will drive demand. He recommends an expansion of the number of federallyfunded medical residency slots based on current health care utilization rates. Strategies to improve the economic reality for U.S. primary care physicians would support new physicians in choosing primary care as a career. Incentives to work in under-served communities, including better pay for primary care physicians, could induce more residents to practice primary care. Approximately 15% of U.S. primary care practices are now recognized as medical homes. While getting the remaining 85% of practices to provide culturally competent While New York State has seen a significant increase in the number of approved Patient-Centered Medical Homes and HANYS members have embraced this care approach, without an adequate primary care workforce the state will be challenged to meet its goal of widespread Advanced Primary Care, as articulated in the 2013 New York State Health Innovation Plan. 2 Atlantic Monthly: Curing the Physician Shortage: Systemic Change to Breed the Doctors We Need, Ben Gallagher, August a fundamental shift in reimbursement must occur to mitigate rising health care costs. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 5

10 The 2011 AAMC Physician Workforce Profile shows that New York State only retains 36% of physicians from undergraduate medical education, which places the state at 28 th in the nation for retaining graduating medical students. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 6

11 State Data on the Physician Shortage Based on data from the Health Resources and Services Administration (HRSA), the Commissioner of Health recently stated that New York needs more than 1,100 primary care physicians to eliminate the state s Health Professional Shortage Areas. According to a study by the Kaiser Family Foundation, New York State is only meeting 40% of its primary care needs. This is one of the lowest rates in the country. A State University of New York (SUNY) Center for Health Workforce Studies (CHWS) brief published in August 2013 reported that more than three million New Yorkers lack access to primary care services. 3 In New York State, only 28% of physicians provide primary care, compared with 32% nationally. New York s primary care physicians are older than physicians in other specialties in the state, and are not as racially and ethnically diverse as the state s population. The paper also reveals that only 33% of nurse practitioners (NPs) and 22% of physician assistants (PAs) are actively providing primary care. This is troubling, as many have looked to NPs and PAs to fill the primary care gaps, especially in rural and under-served areas. The 2011 AAMC Physician Workforce Profile shows that New York State only retains 36% of physicians from undergraduate medical education, which places the state at 28 th in the nation for retaining graduating medical students. In its most recent resident exit survey, CHWS reported that the state only retains 44% of newly trained physicians, and most (86%) of those physicians plan to practice in the same region in which they trained. 4 This poses serious recruitment problems for areas in New York State that do not have residency programs, particularly rural counties. CHWS also reported that the demand for generalists has surpassed the demand for specialists in New York State. Adding to the difficulty for rural communities, a recent brief published by CHWS indicates that a significantly larger proportion of physicians in rural counties plan to retire and/or reduce patient care hours in the next 12 months, with Central New York having the highest percentage of physicians who are planning to retire. 5 CHWS further reports that general surgeons and obstetricians/gynecologists are more likely to plan to retire or reduce patient care hours compared to other specialties. 3 New York s Primary Care Workforce, CHWS, August New York Residency Training Outcomes, CHWS, March New York Physicians Plans to Retire or Reduce Patient Care Hours, 2010, CHWS, June DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 7

12 DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 8

13 Survey Findings Need for Primary Care Physicians Respondents to HANYS survey reported a total need for 1,026 physicians, of which 266 are primary care physicians (26%). Seventy percent of respondents indicated that recruitment of primary care physicians was very difficult, often due to a shortage (75%) and the aging of the primary care workforce (70%). Sixty-three percent of hospital/health system respondents said that their primary care capacity was insufficient to meet patient needs. Seventy-seven percent plan to directly employ primary care physicians for their outpatient sites, but are having difficulty recruiting them. HANYS also asked about the types of outpatient facilities that hospitals/health systems operate. Seventy-six percent indicated that they operate off-site extension clinics, 55% have off-site hospital-owned ambulatory care practices, and 60% said that they had on-site ambulatory care practices. Less than 3% indicated that they had no primary care sites. These data strongly suggest that while hospitals and health systems are focusing resources on primary care, the shortage of primary care physicians will create significant obstacles to the state s vision of widespread implementation of an Advanced Primary Care model. Even if members could meet much of their primary care needs by hiring non-physician clinicians, many respondents indicated they were having difficulty recruiting both NPs (59%) and PAs (55%). This is consistent with the CHWS findings that many NPs and PAs are not providing primary care services, but rather are going into specialty care. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 9

14 Change in Overall New York Physician Supply and Migration Recruitment of physicians continues to lag behind need. Overall, responding hospitals indicated that a total of 4,027 new physicians joined their medical staffs between September 2012 and September Yet, 4,093 physicians left their medical staffs during the same period, for a net loss of 66 physicians. 76% 87% of respondents indicated that physicians are leaving their communities because of retirement. indicated that their ability to recruit physicians was the same or worse since last year. As stated earlier, respondents also reported a need for an additional 1,026 new physicians. When factoring in that not all hospitals and health systems are included in the respondents to this survey, the statewide need number would likely be significantly higher. The breakout by specialty is indicated below. Need for Physicians by Specialty 17% 4% 5% 6% 8% 26% 12% Primary care Surgical sub-specialists Internal medicine sub-specialists Hospitalists ED Orthopedists Psychiatrists General surgeons All others 11% 11% DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 10

15 Overall, 23% of physicians at responding facilities are employed by the hospital, but of those physicians joining medical staffs in the past year, 30% are employed by the hospital. The growth in the number of directly employed physicians is a national trend as younger physicians seek a different quality of life than their predecessors. Many other physicians who are in solo or small group practices and are overwhelmed by health care reform requirements are looking to have hospitals purchase their practices. HANYS asked its members if physicians in their communities are asking to be employed by the hospital or have the hospital purchase their practices. Eighty-four percent of respondents indicated that they have been approached by private physicians in their communities seeking employment, and 81% indicated that private practices in the community are looking to be purchased by the hospital. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 11

16 Patient-Centered Medical Homes and Health Homes Also known as medical homes, Patient-Centered Medical Homes (PCMH) are an approach to providing comprehensive primary care that facilitates partnerships between patients and their personal providers, and, when appropriate, the patient s family. Medical homes provide better access to primary health care, increased satisfaction with care, and improved outcomes. However, the lack of primary care providers will create significant obstacles to the creation of PCMHs. Integral components of the PCMH model include the primary care physician, a patientcentric approach to care, and an interdisciplinary care team that collectively takes responsibility for the health of the patient. With primary care being one of the most important building blocks for healthy communities, New York s hospitals and their physicians have enthusiastically embraced the PCMH model. Many hospital-based and affiliated primary care practices and dozens of New York hospital/health system-affiliated primary care practices have achieved PCMH recognition from the National Committee for Quality Assurance (NCQA), many at the highest level (Level III). Additionally, 61 New York State teaching hospitals are participating in the Department of Health (DOH) Teaching Hospital-Medical Home Demonstration Program, which includes a benchmark of achieving PCMH recognition in More than 100 primary care residency programs operating in more than 150 outpatient primary care sites participate in this demonstration. Sixty-five percent of respondents indicated that they were in the process of becoming PCMHs, with 26% indicating that all or most of their clinics are already PCMHs. Hospitals and health systems are well positioned to continue this transition, but the inability to recruit primary care physicians and non-physician clinicians can hamper progress. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 12

17 HANYS asked respondents about the number of their ambulatory care clinics that have achieved PCMH status. The chart below reflects the percentage reporting whether all, most, some, or none of their clinics had achieved PCMH status. Percent of Respondents by PCMH Status 36% 39% 30% 24%25% 20% 20% 17% 10% 9% 6% 0% All clinics Most clinics Some clinics No clinics PCMH Applied for PCMH Health Homes are also designed to be patient-centered systems of care that facilitate access to and coordination of the full array of primary and acute care, focusing on the chronically ill and behavioral health population. Other critical services include behavioral health and long-term community-based services and supports. The Health Home model is highly dependent on linkages in the community and enhanced coordination of service delivery to better meet the needs of people with multiple chronic illnesses. Like PCMHs, this model aims to improve health care quality and clinical outcomes as well as the patient care experience, while reducing per capita costs through more cost-effective care. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 13

18 Health Home Status of Hospital Clinics 50% 53% 45% 40% 30% 24% 26% 20% 10% 0% 6% 7% 2% 1% All clinics Most clinics Some clinics No clinics Health Home Applying for Health Home DOH defines a Health Home as a care management service model whereby all of an individual s caregivers communicate with one another so that all of a patient s needs are addressed in a comprehensive manner. This is done primarily through a care manager who oversees and provides access to all of the services an individual needs to stay healthy, out of the emergency room, and out of the hospital. Health records are shared (either electronically or by paper) among providers so that services are not duplicated or neglected. Health Home services are provided through a network of providers, health plans, and community-based organizations. When all the services are considered collectively, they become a virtual Health Home. It is not surprising that many of the hospitals/health systems that responded to the survey have not been able to create them, as they require a large network of providers, which may be missing in many geographic areas. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 14

19 Electronic Medical Records New York s hospitals and health systems are making great strides toward the use of Electronic Medical Records (EMRs), which is another critical component of the PCMH model. 86% 93% percent of survey respondents indicated that their primary care clinics are linked to the hospital s EMRs. Of those, are utilizing it at some level. Percent of Respondents Who are Linked and Utilizing Hospital EMRs 40% 44% 45% 30% 20% 22% 17% 25% 26% 10% 0% 6% All clinics Most clinics Some clinics No clinics 0% Linked Utilizing DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 15

20 STRATEGIES TO HELP INCREASE ACCESS TO PRIMARY CARE SERVICES Care Coordination and Interdisciplinary Care Teams Other critical components of the PCMH model include care coordination and the use of interdisciplinary teams, which create efficiencies by enabling health care professionals to practice at their full level of competence. contain outdated supervision rules that are neither practical nor necessary, the article states, noting that the concept of enabling all health professionals to practice at their full level of competence is vital to the success of innovations driven by the ACA. An article in the November issue of Health Affairs discusses the importance of ACA provisions involving effective care delivery through a PCMH. 6 The authors state that effective care involves a team s shared responsibility for patient care, including some role overlap. Current scope of practice laws may either prohibit the person from providing the service or The findings in the chart below show the progress that is being made by hospitals/health systems in these areas. 6 Dower, C, Moore, J, Langeler, M. It is Time to Restructure Health Professions Scope of Practice Regulations to Remove Barriers to Care, Health Affairs, November 2013 vol. 32 No Percent of Respondents Utilizing Care Coordination and Interdisciplinary Teams 40% 44% 42% 30% 20% 18% 24% 16% 19% 10% 10% 8% 0% All clinics Most clinics Some clinics No clinics Care Coordination Interdisciplinary Teams DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 16

21 Strategies to Enhance Primary Care Access HANYS asked hospitals about specific strategies they were using to increase access to primary care services. STRATEGY PERCENT USING STRATEGY Hiring more primary care physicians 81% Hiring more non-physician clinicians 80% Extending office hours to evenings 65% Extending office hours to weekends 57% Enabling patients to call an NP, PA, or physician at the office 56% While most respondents are very focused on hiring more primary care physicians and non-physician clinicians, 70% indicated that they were experiencing difficulty hiring primary care physicians. The shortage of primary care physicians explains the difficulty with recruitment. Further, 59% indicated that they had difficulty hiring NPs and 55% indicated that they had difficulty hiring PAs. The likely explanation is that many NPs and PAs are providing more specialized care. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 17

22 SPECIALTY CARE Recruitment and Retention of Other Physician Specialties While the recruitment of primary care physicians was by far the most difficult, other specialists were also difficult to recruit. SPECIALIST PERCENT REPORTING RECRUITMENT DIFFICULTY Psychiatrists 52% Surgical sub-specialists 48% Orthopedists 44% Emergency physicians 41% General surgeons 37% Internal medicine sub-specialists 36% As indicated in the chart below, respondents said that multiple specialist types were either aging out or in short supply. Aging Out and Shortages of Physicians by Specialty 75% 70% 60% 58% 61% 40% 37% 40% 42% 26% 20% 0% Primary care Adult psychiatrist Surgical subspecialists Orthopedists Shortage Aging out DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 18

23 Difficulty with Recruitment and Retention of Physicians Primary care 15% 70% Emergency 25% 41% General surgeons 20% 37% Internal medicine sub-specialists 9% 36% Orthopedists 21% 44% Psychiatrists 41% 52% Surgical sub-specialists 32% 48% Retention Recruitment While respondents indicated high levels of difficulty with respect to recruiting certain specialists, they reported less difficulty with retention. Emergency Department Coverage and On-call Pay Another clear indicator of the physician shortage is the lack of availability of certain subspecialists in a community for emergency care. Each year, HANYS asks about the lack of coverage of certain specialties at hospitals which can require facilities to transfer patients elsewhere. Sixty-one percent of the respondents indicated that there were times that their emergency department lacked coverage for certain specialties because of the physician shortage. Those specialties that were reported as lacking coverage most often were: Surgical sub-specialists 38% Neurologists/surgeons 33% Medical sub-specialists 30% DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 19

24 Additionally, 32% of respondents said they had to reduce and/or eliminate services at their hospitals in because of a lack of physician coverage. To cope with these shortages, 78% of respondents indicated that they pay for on-call services, primarily for the following specialties: General surgeons 51% Surgical sub-specialists 43% Neurologist/neurosurgeons 42% Orthopedists 37% Telemedicine is another strategy to gain access to sub-specialty care. HANYS has been successful in changing the requirement for duplicate credentialing of health care professionals, which was creating a huge burden for many rural hospitals seeking to provide telemedicine services. This year, HANYS continues to work closely with DOH and other stakeholders to identify and remove other barriers to telemedicine. DANY Funding The Doctors Across New York program helps hospitals and health systems recruit needed physicians to under-served areas by providing financial practice support or loan repayment assistance. HANYS will advocate for new money for DANY during state fiscal year (SFY) to fund 250 awards: 125 loan repayment awards and 125 for practice support. HANYS is collaborating in this effort with members of the Workforce Advisory Group (WAG), a group of stakeholder health care associations. WAG is also advocating for increased funding for the Primary Care Services Corps, a state-funded program that receives federal matching funds to provide loan repayment to NPs, PAs, and other health professionals who work in Health Professional Shortage Areas of the state. Thirty-three percent of the survey respondents indicated that they had successfully applied and received a DANY award, while 18% were unsuccessful in their application. However, 36% indicated that if more funding should become available, they would definitely apply. Fifty-three percent of rural providers received awards. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 20

25 Rural Findings Geographic location is a major factor in recruitment and retention of physicians, and New York s rural hospitals face significant challenges in this regard. Physicians who leave these communities tend to leave for the following reasons: Retiring 72% Seeking a quality of life not available in the community 53% Better economic opportunities elsewhere 47% Primary Care The majority of rural hospitals are providing primary care through on-site and off-site clinics. Many have been making progress toward becoming a PCMH and/or a Health Home. The shortage of primary care physicians (65% of rural hospitals report they do not have sufficient primary care to provide access to their community) is likely the most significant reason that they cannot all achieve PCMH status. Seventy-four percent of rural respondents said they are having difficulty recruiting primary care physicians. TYPES OF OUTPATIENT CLINICS PERCENTAGE OF RESPONDENTS Off-site extension clinics 77% On-site ambulatory care clinics/practices 58% Off-site hospital-owned ambulatory care practices 49% PRIMARY CARE CAPACITY PERCENTAGE OF RESPONDENTS Have plans to expand primary care capacity 88% Plan to directly employ primary care physicians 86% Hiring more non-physician clinicians to provide primary care 74% Experiencing difficulty recruiting primary care physicians 74% Sufficient to meet patients needs 28% DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 21

26 STRATEGIES TO EXPAND ACCESS TO PRIMARY CARE PERCENTAGE OF RESPONDENTS Hiring more non-physician clinicians 81% Hiring more primary care physicians 74% Enabling patients to call physician, PA, or NP with problems 58% Extending office hours to evenings 53% Enabling patient to primary care providers 37% Extending office hours to weekends 33% PCMH and Health Home Status As seen in the chart at right, rural hospitals are making strides toward PCMH status, but primary care shortages and difficulty recruiting non-physician clinicians make it that much more challenging to PCMH 30% 20% 10% 7% 33% 35% 5% 14% 16% 37% 35% meet all of the NCQA standards. Creating Health Homes is a much bigger challenge and requires networks, which explains why rural 0% All clinics Most clinics Some clinics No clinics PCMH Applied for PCMH hospitals have not advanced as quickly in that area. Health Home (HH) Status 60% 40% 20% 0% 5% 7% All clinics 2% 2% Most clinics 12%12% Some clinics 67% 63% No clinics HH Applied for HH The chart at left clearly shows that few rural hospitalbased clinics (19%) have Health Homes or have applied for them (21%). The explanation is fairly simple. Health Homes require an extensive network of providers to meet the needs of the chronically ill and dual-eligible population. The shortage of psychiatrists and a general lack of access to major networks challenges rural hospitals attempting to develop Health Homes without support. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 22

27 Electronic Health Records The vast majority of outpatient clinics that are operated by rural hospitals are both linked and using EHRs. Use of Electronic Health Records Linked to hospital EHR Use EHR 67% 63% 60% 40% 20% 0% 21% 23% 7% 12% 2% 0% All clinics Most clinics Some clinics No clinics Outpatient clinics at rural facilities have largely embraced care coordination and the use of interdisciplinary teams, with 81% indicating some level of care coordination and 70% utilizing interdisciplinary teams. The following chart shows the percentage of respondents that have adopted both practices in their care delivery. Care Coordination and Interdisciplinary Care Teams 30% 26% 26% 30% 30% 20% 21% 19% 19% 14% 10% 0% ALL MOST SOME NONE ALL MOST SOME NONE All clinics Most clinics Some clinics None Care coordination Interdisciplinary care teams DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 23

28 Physician Need The rural hospitals that responded to this survey reported a need for 360 new physicians. The chart below represents a breakdown by specialty for rural hospitals. Need for Physicians 25% 25% 18% 13% 11% 8% Primary care Emergency Hospitalists Internal medicine sub-specialists Surgical sub-specialists All others DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 24

29 SPECIALTY CARE Recruitment and Retention Difficulty While primary care and other specialists are very difficult to recruit, rural hospitals report relatively little difficulty in retaining physicians. A possible explanation is that 63% of rural hospitals employ in-house physician recruiters. These recruiters are better equipped to provide physicians with an orientation to the hospital and the geographic surroundings, which can aid in retention. Recruitment and Retention of Certain Specialists 74% 60% 40% 20% 14% 35% 14% 44% 26% 40% 28% 42% 21% 0% Primary care Emergency Orthopedists Psychiatrists Surgical sub-specialists Recruitment Retention When asked about the reason for the difficulty in recruiting these specialists, hospitals responded as follows: SPECIALTY PERCENT REPORTING RETIREMENTS PERCENT REPORTING SHORTAGE Primary care 65% 77% Surgical sub-specialists 30% 51% Psychiatrists 19% 44% Emergency 9% 40% Orthopedists 42% 40% DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 25

30 Emergency Room Coverage/ Sub-specialty Care Eighty-six percent of rural respondents indicated that there are times when their emergency room is not covered for certain specialties, requiring them to transfer patients elsewhere. The specialists that are reported to be most difficult to find include: Surgical sub-specialists 51% Neurologists/surgeons 51% Medical sub-specialists 47% Orthopedists 35% 67% of rural hospitals pay on-call coverage for certain specialists, with general surgeons (40%) and orthopedists (35%) at the top of the list. As a result of their inability to cover sub-specialty care, 51% of respondents from rural hospitals indicated that they had to reduce and/or eliminate services at their facilities. This is another example of how telemedicine could enable smaller hospitals to provide emergency department coverage. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 26

31 Rural vs. Non-Rural When comparing rural to non-rural facilities, interesting observations include: Rural hospitals are twice as likely to not have ED coverage for certain specialties at times, which requires them to transfer patients elsewhere. Rural hospitals are experiencing greater difficulty recruiting primary care physicians. Rural hospitals have greater difficulty recruiting PAs. Rural hospitals have fewer Health Homes. Rural vs. Non-Rural Lack of ED coverage RURAL NON-RURAL 41% 86% Difficulty recruiting NPs RURAL NON-RURAL 56% 59% Difficulty recruiting PAs RURAL NON-RURAL 63% 47% PCMH status RURAL NON-RURAL 56% 64% Health home status 19% RURAL NON-RURAL 38% Sufficient primary care capacity RURAL NON 28% 14% Difficulty recruiting PCPs RURAL NON-RURAL 64% 86% Ability to recruit same or worsened RURAL NON-RURAL 95% 85% DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 27

32 Regional Data The chart below shows that most regions are losing ground with respect to hiring physicians. Western New York, Rochester, and Central New York all saw net losses. In addition to the net losses, hospitals indicate that they need many more physicians. Net Gain/Loss of Physicians by Region WNY Rochester CNY Northeastern NorMet Nassau/Suffolk Gain Loss DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 28

33 Primary Care Need By Region/Number of Hospitals Reporting Need Number of Hospitals Reporting WNY Rochester CNY Northeastern NorMet Nassau/ Suffolk Rural Non-rural Recruitment Difficulty: Primary Care Physicians by Region 100% 80% 75% 72% 73% 60% 40% 46% 41% 20% 0% WNY Rochester CNY Northeastern NorMet Nassau/Suffolk The chart above reflects the regional response for those who indicated that primary care physicians are very difficult to recruit. Interestingly, the Nassau-Suffolk region has reported the most difficulty with recruitment of primary care physicians. The combination of the high cost of living coupled with the lower pay scale for primary care physicians is likely a strong contributing factor. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 29

34 Reduced/Eliminated Services by Region Hospitals in Western New York and the Rochester region were more likely to reduce or eliminate services, but when comparing rural to non-rural hospitals, rural hospitals were nearly three times more likely to reduce and/or eliminate services. Reduced/Eliminated Services 50% 46% 50% 51% 40% 36% 36% 30% 20% 20% 17% 10% 6% 0% Non-rural ED Not Covered by Specialties at Times 80% 85% 86% 76% 86% 60% 58% 52% 40% 41% 20% 11% 0% WNY Rochester CNY Northeastern NorMet Nassau/ Rural Suffolk WNY Rochester CNY Northeastern NorMet Nassau/ Rural Suffolk Non-rural Again, rural hospitals were twice as likely to report that there were times when their ED was not covered for certain specialties. Regionally, this is more pronounced in both Western New York and the Northeastern region. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 30

35 Conclusions and Recommendations The survey data clearly show that hospitals outside of New York City are struggling with the physician shortage, particularly with respect to primary care. The relatively small percentage of NPs and PAs who practice primary care in the state is also posing a challenge for hospitals and health systems. Policy changes must take place at the state level to increase the number of graduating residents who choose primary care. HANYS recommends: Fund Doctors Across New York to enable 250 awards each year. Expand funding for the Primary Care Services Corps and make statutory language changes to eliminate the competitive procurement process. Eliminate obstacles to providing telemedicine services, especially in hard-hit rural areas. Develop rural and small city residency opportunities. Develop initiatives to create a pipeline of students who would be interested in practicing primary care. Mandate reimbursement for telemedicine services across payers. DOCTOR SHORTAGE: Outpatient and Primary Care Need Growing Results of HANYS 2013 Physician Advocacy Survey PAGE 31

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