THE RURAL HEALTH CARE WORKFORCE TODAY AND TOMORROW

1. THE RURAL HEALTH CARE WORKFORCE TODAY AND TOMORROW Mark Doescher, MD, MSPH Director, WWAMI Rural Health Research and UW Center Center for Health Workforce Studies University of Washington School of Medicine Office of Rural Health Policy Grantee Partnership Meeting August 31, 2009 Washington, DC

2. Acknowledgments This University of Washington WWAMI Rural Health Research Center is funded by the Office of Rural Health Policy, Health Resources and Services Administration, Department of Health and Human Services.

3. Goals and Objectives • Summarize rural workforce trends in four disciplines: • RNs • Dentists • General Surgeons • Primary Care Providers • Examine the primary care pipeline to highlight key workforce supply factors. • Engage in discussion with audience on how to ensure a bright future for the rural health care workforce.

4. Part 1 The Rural Health Care Workforce • Registered Nurses • Dentists • General Surgeons • Primary Care Providers

5. Overarching Rural Workforce Issues The rural health care workforce is subject to: • Low overall supply • Uneven distribution • Need for generalists in an ever specializing world

6. Global Rural Workforce Issues • The rural health care workforce needs professionals: • who are willing to work long hours and • who are adequately prepared to take care of the needs of aging populations. • However, new health care professionals work fewer hours than their predecessors and often have a narrower range of skills.

7. Registered Nurses

8. Issue Overall shortages and regional maldistribution of RNs in rural areas of the US are expected to grow as: “baby boomer” RNs retire. more RNs commute to urban areas for jobs. Registered Nurses (RNs)

9. Evidence An RN shortage of more than 1 million RN FTEs by 2020 has been projected. Registered Nurses National Center for Health Workforce Analysis. (2004). Projected supply, demand and shortages of registered nurses: 2004-2020.

10. Evidence The average age of RNs living in rural and urban areas in 2004 was 45 years. Rural RNs’ average age in 2004 was 6 years older than it was in 1980. 20% of rural RNS were age 55 or older. Registered Nurses Skillman SM, et al. Changes in the rural registered nurse workforce from 1980 to 2004. Final Report #115. Seattle, WA: WWAMI RHRC; Oct 2007.

11. Registered Nurses Skillman SM, et al. Changes in the rural registered nurse workforce from 1980 to 2004. Final Report #115. Seattle, WA: WWAMI RHRC; Oct 2007.

12. Evidence Large percentages of RNs living in rural locations now commute to more populated locations. Commuting RNs are younger than those who work in the rural locations in which they reside. Registered Nurses Skillman SM, WWAMI Rural Health Research Center, University of Washington. Policy brief: threats to the future supply of rural registered nurses. Seattle, WA: Author; Apr 2009.

13. Dentists

14. Issue Rural populations have fewer dentists, lower dental care utilization and higher rates of dental caries and permanent tooth loss than urban populations. Reports from the Surgeon General and the IOM call for more dentists in rural locations. Federal and state programs have focused on expanding oral health care provider supply to increase dental access and improve oral health. Dentists Department of Health and Human Services. 2000. Oral Health in America: A Report of the Surgeon General. Rockville, Md. Doescher et al. 2009; WWAMI RHRC; report pending.

15. Evidence Of the 2,050 rural counties, 1,221 (60%) are designated dental health professional shortage areas (HPSAs). In 2008, there were 21 “generalist” (general practice, pediatric) dentists per 100,000 persons in rural areas compared with 30 in urban areas. Dentists Doescher MP, et al. WWAMI Rural Health Research Center, University of Washington. Policy brief: the crisis in rural dentistry. Seattle, WA; Apr 2009.

16. Dentists Doescher MP, et al. WWAMI Rural Health Research Center, University of Washington. Policy brief: the crisis in rural dentistry. Seattle, WA: Author; Apr 2009.

17. Evidence Rural areas had a higher percentage of generalist dentists aged 56 or older than urban areas (43.8% vs. 38.0%). This percentage was greatest in remote rural locations. Dentists Doescher MP, et al. WWAMI Rural Health Research Center, University of Washington. Policy brief: the crisis in rural dentistry. Seattle, WA; Apr 2009.

18. Dentists Doescher MP, et al. WWAMI Rural Health Research Center, University of Washington. Policy brief: the crisis in rural dentistry. Seattle, WA; Apr 2009.

19. EVIDENCE In 2004, dentists working at rural federally-qualified community health centers were in high demand and short supply. Almost half of rural CHCs had vacant dentist positions for over 7 months. Dentists Rosenblatt RA, et al. 2006. Shortages of medical personnel at community health centers: implications for planned expansion. JAMA. Mar 1 2006;295(9):1042-1049.

20. General Surgeons

21. Issues Rural general surgeons perform emergency operations, underpin the trauma care system, and back-up primary care providers. Without surgical services, small hospitals often fail, which reduces community employment and jeopardizes local healthcare. The dramatic decline in the number of rural general surgeons in the US since the early 1980s has precipitated a crisis in rural general surgery. General Surgeons Lynge DC, et al. 2008. A longitudinal analysis of the general surgery workforce in the United States, 1981-2005. Arch Surg. 143(4):345-50.

22. Evidence Between 1981 and 2005, the number of rural general surgeons per 100,000 population declined by 21%. In 2005, there were 5.0 general surgeons per 100,000 persons in rural areas compared with 5.9 in urban areas. This number was only 4.3 for smallnonadjacent rural counties. General Surgeons Lynge DC, et al. 2008. A longitudinal analysis of the general surgery workforce in the United States, 1981-2005. Arch Surg. 143(4):345-50.

23. General Surgeons Number of Rural and Urban General Surgeons Per 100,000 Population, 1981-2005 Lynge DC, et al. 2008. A longitudinal analysis of the general surgery workforce in the United States, 1981-2005. Arch Surg. 143(4):345-50.

24. Evidence The majority of rural general surgeons are approaching retirement age: 52.0% were aged between 50 and 62 in 2005. Women make up an increasing proportion of the rural general surgery workforce: their proportion rose from 1.0% in 1981 to 8.9% in 2005. International medical graduates make up a smaller proportion of the rural surgery workforce: their proportion declined from 25.3% in 1981 to 14.9% in 2005. General Surgeons Doescher MP, et al.2009. WWAMI Rural Health Research Center, University of Washington. Policy brief: the crisis in rural general surgery. Seattle, WA; April, 2009. Lynge DC, et al. 2008. A longitudinal analysis of the general surgery workforce in the United States, 1981-2005. Arch Surg. 143(4):345-50.

25. General Surgeons Percentage of Rural and Urban General Surgeons Nearing Retirement Age (50-62 Years) Doescher MP, et al.2009. WWAMI Rural Health Research Center, University of Washington. Policy brief: the crisis in rural general surgery. Seattle, WA; April, 2009.

26. Primary Care Providers

27. Issues Primary care plays a critical role in rural health care delivery. Yet the number of U.S. health care students choosing primary care careers has declined precipitously. Factors discouraging recruitment and retention: Low compensation Rising malpractice premiums Professional isolation Limited time off Difficulty finding jobs for spouses Primary Care Providers

28. Primary Care Providers Trends in the Family Medicine Match Adapted from: Bodenheimer T. 2006. N Engl J Med;355:861-864.

29. Issues Within primary care, family physicians constitute the largest proportion of the rural primary care physician workforce. The availability of family medicine residency training opportunities in rural locations provides a critical mechanism for rural supply. Yet training opportunities in rural locations are under threat. Primary Care Providers Chen FM, et al. Policy brief: the availability of family medicine residency training in rural locations of the United States. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, June, 2009.

30. Change in Rural Training FTEs Primary Care Providers Chen FM, et al. Policy brief: the availability of family medicine residency training in rural locations of the United States. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, June, 2009.

31. Evidence Over three-quarters of rural counties are designated as primary care HPSAs. 165 rural counties lacked a primary care physician in 2005. Primary Care Providers Doescher MP, et al.. Policy brief: the crisis in rural primary care. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; April, 2009.

32. Primary Care Providers

33. Evidence In 2005, there were 55 primary care physicians per 100,000 persons in rural areas compared with 72 in urban areas. Rural primary care physicians are older than their urban counterparts, particularly in remote locations. Primary Care Providers Doescher MP, et al. Policy brief: the aging of the primary care physician workforce: are rural locations vulnerable? Seattle, WA: WWAMI Rural Health Research Center, University of Washington; June, 2009.

34. Primary Care Providers Near-Retirement Age Primary Care Physicians Doescher MP, et al. Policy brief: the aging of the primary care physician workforce: are rural locations vulnerable? Seattle, WA: WWAMI Rural Health Research Center, University of Washington; June, 2009.

35. Primary Care Physicians Per 100,000 Population, 2005 Primary Care Providers

36. Evidence Rural areas increasingly rely on PAs and NPs for primary care. 34% of the primary care workforce in Wyoming 46% of the direct clinical care providers at rural CHCs. Primary Care Providers Skillman SM, et al. Wyoming primary care gaps and policy options. Final Report #122. Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington; Dec 2008.

37. Evidence In 2004, rural CHCs had significantly higher proportions of unfilled positions and more difficulty recruiting family physicians than urban CHCs more than one third of rural CHCs spent over 7 months recruiting a family physician. Primary Care Providers Rosenblatt RA,et al. Shortages of medical personnel at community health centers: implications for planned expansion. JAMA. Mar 1 2006;295(9):1042-1049.

38. An in-depth presentation of efforts to address rural primary care shortages Rationale: Primary care is a critical ingredient of the rural health care workforce. The primary care workforce is relatively well-studied. Many of the factors affecting rural primary care are relevant for other health care disciplines. Part 2: The Rural Primary Care PipelineAn Illustration of Factors that Influence Supply

39. The Challenge: Most training is in the city…

40. …but we need folks who choose to work here.

41. The benefit of primary care-based health care delivery: More preventive care Better quality of care More equitable care Better population health outcomes, including lower mortality Lower costs Primary Care Starfield, B., L. Shi, and J. Macinko. 2005. “Contribution of Primary Care to Health Systems and Health.” Milbank Quarterly 83(3): 457-502.

42. Primary care and health care-sensitive outcomes Starfield B, Simpson L. 1993. Primary care as part of U.S. health services reform. JAMA; 269:3136-9.

43. Primary care and health care expenditures Starfield B, Simpson L. 1993. Primary care as part of U.S. health services reform. JAMA; 269:3136-9.

44. The decline of primary care in the U.S. • Despite the benefits of having a strong system of primary care, new physicians are increasingly choosing specialties over primary care. • Primary care shortages persist throughout US, particularly in rural and inner city locations. • Evidence of growing problems of access to primary care.

45. New physicians entering specialties Institute of Medicine (IOM). 1994. Changing the Health Care System: Models from Here and Abroad.

46. Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists Bodenheimer T. N Engl J Med 2006;355:861-864.

47. Estimates suggest that increased insurance uptake under health care reform would increase the workload of existing primary care physicians by roughly 30% between now and 2025. By the same period, the supply of primary care physicians will rise by only 7%. This would lead to a shortfall of 35,000 to 44,000 primary care physicians who treat adults. Overall population growth and a growing elderly population are driving the projected shortfall. Decline of primary care in the U.S. Source: Spyros Andreopoulos. Doctor shortage imperils Obama's health care reform San Francisco Chronicle, Sunday, December 21, 2008

48. >750 vacancies for PCPs at Community Health Centers (2004)

49. The number of medical students choosing training in internal medicine, family medicine and geriatrics is down and many physicians now in practice are leaving the field. The extent to which primary care NPs and PAs will make up this gap is not known. Factors before medical school matriculation Educational environment: medical school and residency training Practice environment Compensation and debt burden Work/life satisfaction: long working hours; the complexity of dealing with chronically ill patients; paperwork Why primary care is in trouble

50. We do not do a good job of producing our own rural workforce.Rural physicians are 3x more likely than their urban counterparts to come from a rural background.But many rural educational systems are inadequate to the task of producing health care professionals. Factors before medical school matriculation