Who we are and what we do

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1 Medical Education in North Carolina: What is the Return on Investment? Julie Spero, MSPH Erin Fraher, PhD MPP Who we are and what we do Program on Health Workforce Research & Policy Cecil G. Sheps Center for Health Services Research NC AHEC Statewide Conference September 11, 2015 North Carolina Health Professions Data System (HPDS) Mission:to provide timely, objective data and analysis to inform health workforce policy in North Carolina and the United States Based at Cecil G. ShepsCenter for Health Services Research at UNC-CH, but mission is statewide A collaboration between the ShepsCenter, NC AHEC and the health professions licensing boards System is independent of government and health care professionals North Carolina s health workforce data are the envy of the other 49 states 35 years of continuous, complete licensure (not survey) data on 19 health professions from 12 boards Data are provided voluntarily by the boards there is no legislation that requires this, there is no appropriation Data housed at Shepsbut remain property of licensing board, permission sought for each new use System would not exist without data and support of licensure boards Fears of physician shortages create headlines but we see steady increase in supply Physicians per 10,000 population, North Carolina and United States, The Physician Workforce in NC Sources: North Carolina Health Professions Data System, 1979 to 2013; American Medical Association Physician Databook, selected years; US Census Bureau; North Carolina Office of State Planning. North Carolina physician data include all licensed, active, physicians practicing in-state, inclusive of residents in-training and federally employed physicians, US data includes total physicians in patient care, which is inclusive of residents-in-training and federally employed physicians.us physician data shown for 1980, 1985, 1990, 1994, 1995, 2004, 2005, 2007, 2009, 2011, 2012, 2013; all other years inputed. 1

2 The real issue is maldistribution Physicians per 10,000 population by Persistent Health Professional Shortage Area (PHPSA) Status, North Carolina, Where can we intervene? Notes: Figures include active, instate, nonfederal, non-resident-in-training physicians licensed as of October 31st of the respective year. North Carolina population data are smoothed figures based on 1980, 1990, 2000 and 2010 Censuses. As of 2012, Primary Care PHPSA calculations updated with data from most recent AHRF release. Persistent HPSAs are those designated as HPSAs by HRSA using most recent 7 HPSA designations (2004, ). Sources: North Carolina Health Professions Data System, 1980 to 2013; North Carolina Office of State Planning; North Carolina State Data Center, Office of State Budget and Management; Area Health Resource File, HRSA, Department of Health and Human Services. Different interventions at different points in a physician s career path Goal: A physician workforce that meets NC s population health needs Intervention points: Medical School Residency Initial practice location Practice in an underserved area What is our return on investment of public funds? Medical School NC has recently expanded Medical School Enrollments North Carolina expanded medical school enrollment UNC expanded from 160 to 180 positions with regional placements in Charlotte and Asheville for 3 rd and 4 th year students ECU expanded from students Campbell admitted first class of 150 students in September 2013 These expansions are not likely to improve workforce supply and distribution in the state Why not? 2003 Medical School Graduates: Retention in Primary Care in NC s Rural Areas 10 years later Total number of 2003 NC med school grads in training or practice in Initial residency choice in primary care in (59%) In training or practice in primary care in (34%) In primary care in NC in (18%) In primary care in rural NC in (3%) Produced by the Program on Health Workforce Research and Policy, Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Source: North Carolina Health Professions Data System with data derived from the Association of American Medical Colleges, and the NC Medical Board, Rural source: US Census Bureau and Office of Management and Budget, March Core Based Statistical Area (CBSA) is the OMB s collective term for Metropolitan and Micropolitan Statistical areas. Here, nonmetropolitan counties include micropolitan and counties outside of CBSAs. 2

3 Need to develop NC training tracks: Retention much higher for physicians completing both UME and GME instate Residency As of 2012: Source: AAMC 2013 State Data Book, with data derived from the 2012 AMA Physician Masterfile. NC still has more first-year residency positions than medical school grads NC Medical School Campbell (Osteopathic) 150 Duke 115 ECU 80 UNC 180 Wake Forest 120 TOTAL 645 Number of First-Year Students Need to target expansions to community-based and AHEC residencies NC had 693 available First Year (PGY-1) Residency Positions in 2014* Data from 2015 NRMP Main Residency Match and do not include specialties who do not participate in the match New DO residencies are being created in NC: 72 added in debruyn J. Campbell Medical school doubles residency positions to , November 28. Triangle Business Journal. Accessed August 11, 2015 at campbell-medical-school-doubles-residency.html. Completing an AHEC residency increases in-state retention AHEC 50% (n=1,420) of physicians who complete an NC AHEC residency stay in North Carolina to practice Non-AHEC compared to 38% (n=5,879) of physicians who complete a non-ahec residency stay in North Carolina to practice Source: NC Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, with data derived from the American Medical Association Masterfile, "Active" includes federal, as well as non-patient care activities such as teaching, research, administration, etc. For primary care physicians, in-state retention of AHEC residents is greater than non-ahec residents 70% 60% 50% 40% 30% 20% 10% Primary Care Physicians Practicing in NC who Completed an NC Residency, AHEC vs. Non-AHEC Residency, % (n=1,194) (n=2,284) (n=691) (n=627) (n=244) (n=810) (n=118) (n=565) Source: NC Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, with data derived from the American Medical Association Masterfile, "Active" includes federal, as well as non-patient care activities such as teaching, research, administration, etc. (n=141) (n=282) Total for Primary Care Family Medicine Internal Medicine Pediatrics OBGYN AHEC Residency in NC Non-AHEC Residency in NC 3

4 Sources of GME funding in North Carolina Biggest barrier to residency expansion in NC is cost, estimated at ~$145,000 per resident, per year. Residency costs covered from four sources of revenue: Medicare direct and indirect payments to teaching hospitals (dominant source) Medicaid GME payments to teaching hospitals NC: $116 million, 5 th highest in US* Clinical income State appropriation to AHEC ~$32 million Accountability for residency outcomes is critical but hard to implement Virtually no accountability for Medicare or Medicaid GME funds No state tracks outcomes of public investments in GME Need to track trainees 10 years out since specialization is a long process Teaching hospitals focus on GME expansion for service lines and will resist accountability until tied to funding * Henderson T. Medicaid Graduate Medical Education Payments: A 50 State Survey. Washington, DC Loan repayment programs provide support in the first practice location Beyond Training: Interventions Later in the Career Path NC has state and Federal loan repayment programs for: Primary care physicians Psychiatrists Nurse Practitioners (NPs) Physician Assistants (PAs) Nurse Midwives Dentists New Legislation: state support for General Surgeons at critical access hospitals and funds for telehealth Practice support programs help retain physicians in rural areas AHEC AHEC Digital Library Practice Support Program (PSP) NC Health Information Technology Regional Extension Center (HITREC) NC Medical Society Community Practitioner Program Strategic approach: intervene at different points in career path 4

5 Many points where can intervene to promote distribution of workforce to meet NC s population health needs Health Care = a Team of Providers Explosive Growth in NC s NP & PA Workforce Cumulative rate of growth per 10,000 population since 1990: physicians, nurse practitioners and physician assistants in North Carolina New roles are developing in the changing health system Examples: Pharmacists medication management for chronic disease Care coordination Nurses, social workers, others Health coaches Need to think about the entire healthcare team Local level: what is the most efficient way to meet healthcare needs in this community? Sources: North Carolina Health Professions Data System with data derived from the North Carolina Medical Board and North Carolina Board of Nursing, 1990 to Figures include all active, instate, non-federal, non-resident-in-training physicians, PAs and NPs licensed as of October 31 of the respective year. Produced by: Program on Health Workforce Research and Policy, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Questions? Julie Spero (919) juliespero@unc.edu Program on Health Workforce Research & Policy 5