Pediatric Workforce Shortages: Policy and Advocacy Challenges

1

• Pediatric Workforce Shortages Policy and
  Advocacy Challenges

2
Overview The Pediatrician Workforce

• The general pediatrician pipeline
• Pediatric subspecialty shortages
• Potential solutions
• Questions?

3
General Pediatricians
4
General Pediatricians Training Board
Certification

• After 4 years of college, pediatricians must
  complete 4 years of medical school, traditionally
  followed by 3 additional years of residency
  training.
• In order to qualify for board certification in
  general pediatrics, pediatricians who have
  completed residency training must sit for and
  pass a rigorous 2-day examination, administered
  by the American Board of Pediatrics.
• Ongoing, continuing medical education (CME) is
  also required to maintain board-certified status.
  
• The pediatrician, because of extensive training
  and commitment to lifelong pediatric learning,
  is the most qualified provider of pediatric
  primary health care.

5
YEARS of Formal Education (at Time of Completion)
General pediatricians
Pediatric subspecialists
6
How Many General Pediatricians Are There?

• The general pediatrician pipeline is extremely
  important, as it represents the pool of
  potential pediatric fellowship trainees and,
  ultimately, determines the number of pediatric
  medical subspecialists and surgical specialists.

Total Active (2009) Male Female Board-Certified Non-Board-Certified
58,194 24,301 33,893 43,972 14,222
Source Physician Characteristics and
Distribution in the US, 2011 Edition (American
Medical Association)
7
State Pediatrician-to-Population Ratios( of
children for each general pediatrician)
Alabama 2,2291 Kentucky 2,5141 North Dakota 2,7551
Alaska 2,2921 Louisiana 1,9941 Ohio 1,8151
Arizona 2,1931 Maine 1,7171 Oklahoma 2,6801
Arkansas 2,7971 Maryland 1,1431 Oregon 2,0491
California 1,8281 Massachusetts 1,0401 Pennsylvania 1,6231
Colorado 1,9661 Michigan 2,0181 Rhode Island 1,2271
Connecticut 1,2201 Minnesota 2,2341 South Carolina 2,2201
Delaware 1,2891 Mississippi 2,8331 South Dakota 3,6411
DC 4841 Missouri 1,8681 Tennessee 1,9301
Florida 1,6051 Montana 2,7591 Texas 2,4211
Georgia 1,9141 Nebraska 2,6081 Utah 2,5511
Hawaii 1,2421 Nevada 3,0541 Vermont 1,2361
Idaho 4,2801 New Hampshire 1,5771 Virginia 1,5901
Illinois 1,7701 New Jersey 1,1251 Washington 2,0551
Indiana 2,7141 New Mexico 2,1581 West Virginia 2,0681
Iowa 3,0041 New York 1,0681 Wisconsin 2,1001
Kansas 3.3001 North Carolina 1,8951 Wyoming 3,0771
Source Mapping Health Care Delivery for
Americas Children Project (US Census 2000,
AMA/AOA Masterfiles, 2000)
8
General Pediatrician Supply

• Maldistribution of general pediatricians
• States with large rural areas and fewer training
  programs have biggest shortages
• Physician/population ratios do not adequately
  reflect clinical workload

9
Pediatric Subspecialists
10
What Are Pediatric Subspecialists?

• The term pediatric subspecialist is a global
  term that encompasses all physicians who have
  received special pediatric-specific training in a
  wide range of medical subspecialties, surgical
  specialties, and other medical fields.
• Subspecialists can be grouped into those who
  received their initial training in general
  pediatrics and those who initially trained in
  adult medicine.

11
YEARS of Formal Education (at Time of Completion)
General pediatricians
Pediatric subspecialists
12
Subspecialty Certification by the ABP

• In addition to certification in general
  pediatrics, the American Board of Pediatrics
  (ABP) offers a certificate of special
  qualifications in the following pediatric
  subspecialties

• Adolescent medicine
• Pediatric cardiology
• Critical care
• Child abuse pediatrics
• Developmental pediatrics
• Ped emergency medicine
• Pediatric endocrinology

• Pediatric gastroenterology
• Pediatric heme-onc
• Pediatric infectious diseases
• Neonatal medicine
• Pediatric nephrology
• Pediatric pulmonology
• Pediatric rheumatology

13
Pediatric Subspecialists Training ABP Board
Certification

• Candidates for subspecialty certification must
  complete an additional 3 to 5 years of
  subspecialty training following 3 years of
  residency training, 4 years of medical school,
  and 4 years of college.
• A candidate must have achieved initial board
  certification in general pediatrics and continue
  to maintain that certification in order to take a
  subspecialty examination.
• A candidate must have a current, unrestricted
  license to practice medicine in one of the
  states, districts, or territories of the United
  States.
• Only after successful completion of these
  requirements may a candidate sit for examination
  in a subspecialty.
• Recent passing rates for first-time exam takers
  range from 71.6 (for pulmonology in 2006) to
  93.3 (for sports medicine in 2009).

14
Other Pediatric Subspecialty Training (years)
Adult residency
Pediatric subspecialists
15
Subspecialty Certification by Other Specialty
Boards
Some pediatric subspecialists, particularly
pediatric surgical specialists, are certified by
other specialty boards (such as the American
Board of Otolaryngology). Subspecialties
certified by other boards include

• Adolescent medicine
• Child and adolescent psychiatry
• Pediatric emergency medicine

• Pediatric otolaryngology
• Pediatric pathology
• Pediatric rehabilitation
• Pediatric radiology
• Pediatric surgery

16
So How Many Pediatric Subspecialists Are There?

• Data regarding this question varies, but the most
  expansive definition of pediatric
  subspecialistswhich would include surgical
  specialists and other specialist
  physiciansplaces the number at around 27,400
  (AMA, 2009).
• The 2010 U.S. Census counted more than 75 million
  children under the age of 18 nationwide.

17
AN IMPORTANT CAVEAT

• That number (27,400) is not likely to equal the
  actual number of pediatric subspecialists who are
  actively caring for children.
• Not all physicians are actively engaged in
  patient care.
• Administrative work
• Academic Teaching
• Research
• Other
• Not all physicians are working full-time.

18
When a Community Lacks Pediatric Subspecialists

• Care may be provided by adult medicine
  subspecialists who lack appropriate training in
  pediatric care.
• Care for children who have complex illnesses may
  be provided by general pediatricians.
• Families must travel to a distant center for
  care.
• Families may need to relocate to another
  community.

19
Why Is Pediatricas Opposed to AdultSubspecialty
Care Important?

• Pediatric subspecialty care
• Improves quality of care for children
• Diagnosis, management, outcome
• Lowers complication rates
• surgical procedures
• Decreases medical costs
• Shorter length of stay and lower hospital charges
  

20
Why Is Pediatricas Opposed to AdultSubspecialty
Care Important?

• Pediatric subspecialty care is associated with
• Shorter length of stay for closed femoral shaft
  fractures when treated by a pediatric orthopedic
  surgeon (JT Smith et al., 1999).
• Shorter time spent by young children treated for
  fever in the pediatric emergency department
  (Isaacman et al., 2001).
• Lower complication rates and shorter lengths of
  stay for children with significantly perforated
  appendicitis when treated by pediatric surgeons
  (Alexander, 2001).
• Increased precision in tumor removal and
  decreased risk of mucosal perforation post
  pyloromyotomy (Albright et al., 2000).
• Shorter lengths of stay and/or lower costs for
  appendectomy and ureteroneocystostomy (Kokoska et
  al., 2001 Snow et al., 1996).
• Reduced length of stay by 40 minutes when
  pediatric emergency medicine physicians treated
  croup (Hampers and Faries, 2002).

21
What Does Pediatric Subspecialty Care Cost, and
What Are the Savings?

• Pediatric emergency medicine physicians treating
  croup reduced direct costs by 90 when compared
  to the same treatment delivered by adult
  emergency medicine physicians (Hampers and
  Faries, 2002).
• Younger children with appendicitis who were
  treated by pediatric surgeons had significant
  shorter hospital stays and/or decreased hospital
  charges than younger children treated by general
  surgeons for the same condition (Kokoski et al.,
  2004).
• Pediatric orthopedic surgeons achieved lower
  hospital charges than adult orthopedic surgeons
  for closed femoral shaft fractures (JT Smith et
  al., 1999).

22
Demand for Pediatric Subspecialists

• These physicians care primarily for children who
  have special health care needs that are beyond
  the scope of primary care physicians (e.g.
  cancer, congenital heart disease).
• As the number of children who have chronic
  illness grows, the demand for pediatric
  subspecialists increases.

23
Subspecialist Supply Indicators of a Shortage
24
Where Do We Find Evidence of Shortages?

• Wait times for subspecialty appointments
• Difficulty referring to subspecialists
• Difficulty recruiting subspecialists
• Distance to care

25
Wait Times
Specialty of hospitals over 2-week benchmark Wait times (business days) Wait times (weeks)
Endocrinology 68 51.4 10.3
Neurology 61 47.6 9.5
Gastroenterology 59 26.5 5.3
Nephrology 52 33.6 6.7
Developmental Pediatrics 50 65.7 13.1
Pulmonology 50 40.7 8.1
Rheumatology 36 31.9 6.4
Orthopedics 34 38.2 7.6
Dermatology 32 66.0 13.2
Urology 30 35.2 7.0

• In 2010, the National Association of Childrens
  Hospitals and Related Institutions (NACHRI)
  reported on the number of weeks patients had to
  wait to obtain subspecialty appointments.
• For 10 subspecialties, patients had to wait
  longer than 5 weeks.
• For 3 subspecialties, patients had to wait longer
  than 10 weeks.

Reproduced from NACHRI, Pediatric Subspecialty
Shortages Affect Access to Care
26
Difficulty Referring

• The percent of pediatric outpatient visits
  resulting in referral increased from 3.5 in 1999
  to 6.1 in 2007 (Merline et al., 2010).
• 68 of rural PCPs and 49 of nonrural PCPs were
  dissatisfied with waiting times for
  subspecialist appointments more than 65 of
  rural and only 19 of non-rural PCPs rated the
  number of subspecialists in their area as poor or
  fair (Pletcher et al., June 2010).
• A recent GAO report found that 84 of physicians
  treating children insured by Medicaid or CHIP had
  great or some difficulty making specialty
  referrals 26 of physicians treating privately
  insured children had great or some difficulty
  making specialty referrals.
• For all children, physicians had the most
  difficulty making referrals for mental health,
  dermatology, and neurology.

27
of Primary Care Pediatricians Reporting Too Few
Subspecialists to Meet the Needs of Patients (by
Subspecialty Type and Practice Location)
Medical Specialty Total (n 590) Non-rural (n 514) Rural (n 76)
Child/adolescent psychiatry 95.8 95.1 100.0
Developmental peds 86.6 85.9 92.0
Pediatric dermatology 81.6 80.5 89.3
Pediatric rheumatology 68.2 67.3 74.0
Pediatric neurology 66.7 66.1 70.7
Adolescent health 64.2 64.2 64.9
Pediatric endocrinology 58.8 57.2 69.3
Pediatric gastroenterology 54.5 53.8 59.2
Pediatric emergency med 49.2 46.4 68.4
Pediatric nephrology 48.1 46.2 61.3
Pediatric genetics 45.1 45.1 44.7
Pediatric pulmonology 41.7 40.2 52.0
Surgical Specialty Total (n 590) Non-rural (n 514) Rural (n 76)
Pediatric orthopedics 54.6 52.3 70.7
Pediatric neurosurgery 49.4 47.9 59.2
Pediatric urology 46.6 44.7 59.2
Pediatric ophthalmology 42.2 38.5 67.6
Pediatric otolaryngology 37.9 35.1 55.3
Reproduced from Pletcher et al. Primary care
pediatricians' satisfaction with subspecialty
care, perceived supply, and barriers to care. The
Journal of Pediatrics. 20101561011-1015.
28
Difficulty Recruiting
Subspecialty Percentage of Organizations Recruiting Percentage of Organizations Reporting Medium to High Difficulty in Recruiting Percentage of Positions Being Recruited for 6 Months or More
Emergency Medicine 33 83 67
Endocrinology 33 75 50
Gastroenterology 33 75 50
General Pediatrics 42 40 60
General Surgery 33 100 100
Nephrology 33 100 60
Neurology 33 100 75
Reproduced from ECG Management Consultants, 2010
ECG Trends Webinar Series, The Pediatric
Subspecialty Market Compensation, Benefits,
Recruitment, and Employment Trends.
29
Difficulty Recruiting

• In 2010, NACHRI compiled a list of pediatric
  subspecialties that have vacancies lasting longer
  than 12 months.

Reproduced from NACHRI, Pediatric Subspecialty
Shortages Affect Access to Care
30
Mean Distance to Care

• Pediatric Subspecialty

• Distance to Care (miles)

• Adolescent medicine
• Critical care medicine
• Developmental pediatrics
• Neonatal medicine
• Neurodevelopment
• Pediatric cardiology
• Pediatric endocrinology
• Pediatric rheumatology
• Pediatric sports medicine
• Pediatric nephrology
• Pediatric gastroenterology

• 42
• 26
• 44
• 15
• 73
• 22
• 26
• 60
• 78
• 36
• 32

Myer ML. Are We There Yet? Distance to care and
relative supply among pediatric medical
subspecialties. Pediatrics. 20061182313-2321.
31
Percentage of children who must travel gt 80
miles to care

• Subspecialty

• Percentage of U.S. Children

• Adolescent medicine
• Critical care medicine
• Developmental pediatrics
• Neonatal medicine
• Neurodevelopment
• Pediatric cardiology
• Pediatric heme/onc
• Pediatric endocrinology
• Pediatric rheumatology
• Pediatric sports medicine
• Pediatric gastroenterology
• Pediatric nephrology

• 19
• 7
• 20
• 4
• 26
• 7
• 8
• 11
• 24
• 30
• 12
• 16

32
Subspecialty Supply Contributing Factors to a
Shortage
33
What Factors Contribute to Subspecialty Shortages?

• Geographic maldistribution
• Low payment to debt ratio
• Mechanism of financing GME

34
Distance to Care

• The population-weighted average distances to care
  ranges from 15 miles for a neonatologist to 75
  miles for a sports medicine specialist.
• A 2005 study by Mayer et al. found that a child
  must travel 27.1 miles to the nearest pediatric
  surgeon and neurosurgeons, and cardiothoracic
  surgeons are far greater.

Mayer ML, Beil HA, von Allmen D. Distance to care
and relative supply among pediatric surgical
subspecialties. Journal of Pediatric Surgery.
200944483-495.
35
Distribution of Subspecialists
Reproduced from Mayer ML, Beil HA, von Allmen D.
Distance to care and relative supply among
pediatric surgical subspecialties. Journal of
Pediatric Surgery. 200944483-495.
36
Distribution of Subspecialists
Reproduced from Mayer ML, Beil HA, von Allmen D.
Distance to care and relative supply among
pediatric surgical subspecialties. Journal of
Pediatric Surgery. 200944483-495.
37
Distribution of Subspecialists
Reproduced from Mayer ML, Beil HA, von Allmen D.
Distance to care and relative supply among
pediatric surgical subspecialties. Journal of
Pediatric Surgery. 200944483-495.
38
Distribution of Subspecialists
Reproduced from Mayer ML, Beil HA, von Allmen D.
Distance to care and relative supply among
pediatric surgical subspecialties. Journal of
Pediatric Surgery. 200944483-495.
39
Distribution of Subspecialists
Reproduced from Mayer ML, Beil HA, von Allmen D.
Distance to care and relative supply among
pediatric surgical subspecialties. Journal of
Pediatric Surgery. 200944483-495.
40
Distribution of Subspecialists
Reproduced from Mayer ML, Beil HA, von Allmen D.
Distance to care and relative supply among
pediatric surgical subspecialties. Journal of
Pediatric Surgery. 200944483-495.
41
Distribution of Subspecialists
Reproduced from Mayer ML, Beil HA, von Allmen D.
Distance to care and relative supply among
pediatric surgical subspecialties. Journal of
Pediatric Surgery. 200944483-495.
42
Distribution of Subspecialists
Reproduced from Mayer ML, Beil HA, von Allmen D.
Distance to care and relative supply among
pediatric surgical subspecialties. Journal of
Pediatric Surgery. 200944483-495.
43
Trends in Average Educational Debt Among
Graduating Pediatric Residents
Source AAP Graduating Resident Survey,
1997-2010. Numbers in 2010 includes spousal
debt.
44
Financing GME

• Federal and (some) state government agencies
  provide a major part of the funding for graduate
  medical education (GME), especially for primary
  care.
• The nature of childrens hospital GME (CHGME)
  funding is uncertain because it is appropriated
  annually in the proposed 2012 federal budget, it
  has been zeroed out.
• Without this crucial funding, many residency
  training programs would be forced to close.
• Many of the poorest patients in the U.S., who
  rely on teaching hospitals, would lose access to
  care.
• Fewer programs and residents would lead to an
  even greater shortage of physicians and further
  reduce access to care.

45
Working toward Solutions
46
What Can We Do Nationally about the Pediatric
Subspecialty Shortage?

• Advocate for continued, consistent support of
  CHGME.
• Target GME to areas of need (provider and
  location).
• Support the appropriation of Section 5203 of the
  ACA (pediatric subspecialty loan repayment
  program) and state loan repayment programs.
• Promote appropriate payment for pediatricians.
• Advance the development of long-term workforce
  policy.
• Encourage the pediatrician-led, patient-centered
  medical home model.

47
What Can States Do?

• Advocate for state contributions to GME.
• Advocate for increased state support for programs
  that improve access to care in underserved areas,
  such as the NHSC and Rural Health Clinics.
• Explore how health information technologies (such
  as telemedicine) may be used to enhance delivery
  of pediatric care by general pediatricians and
  pediatric subspecialists in shortage areas.
• Use workforce and quality of care data to
  advocate for public policy that is the best
  interests of infants, children, adolescents, and
  young adults.
• Provide information to health care policy-makers
  about the unique education, skills, and care
  provided by pediatricians and pediatric
  subspecialists.

48
State Success Stories and Solutions
49
Models

• General pediatricians fill some gaps.
• Other successful models include
• Incentive programs
• Loan repayment programs
• Technical assistance programs.

50
Pediatrician-Provided Dental Care

• 40 state Medicaid/CHIP programs pay pediatricians
  to provide preventive oral health services to
  young children (states not paying for this
  service are AR, AZ, DE, HI, IN, LA, NH, NJ, OK,
  and WV Washington, D.C. also does not pay).
• Dental caries constitute the leading chronic
  infectious disease of early childhood.
• Many young children have difficulty accessing
  care from a dentist due to workforce shortages or
  a lack of dentists in the area willing to care
  for Medicaid/CHIP children.
• Children see the pediatrician frequently in the
  early years therefore, oral health prevention
  could and should take place in the pediatrician's
  office when a dentist is not available.
• Pediatricians can also serve as a referral source
  to dentists in the community who may be willing
  to see young children, but are not aware of the
  need.

51
Pediatrician-Coordinated Mental Health Care

• Arizona Telemedicine Program
• Provides telemedicine services, distance
  learning, informatics training, and telemedicine
  technology assessment capabilities to communities
  throughout the state.
• Established a telemedicine link with the
  University of Arizona Department of Child and
  Adolescent Psychiatry.
• Illinois DocAssist
• Improves delivery/coordination of mental health
  and substance use care by supporting
  Medicaid-enrolled primary care providers treating
  children up to age 21.
• Child/adolescent psychiatrist available statewide
  for phone consultation services.
• Funded by IL Dept. of Healthcare and Family
  Services and IL Dept. of Human Services.
• Massachusetts Child Psychiatry Access Project
• Helps primary care physicians statewide
  effectively respond to mental health concerns.
• 6 regional mental health teams comprised of child
  psychiatrists, therapists, and care coordinators
  led by child psychiatry divisions of academic
  medial centers.
• Funded by the Dept. of Mental Health.
• Vermont Upper Valley Pediatrics
• Staff includes 1 pediatrician and 7 mental health
  therapists and LCSWs.
• LCSWs and therapists deliver psychotherapeutic
  services at the practice site.
• Credentialed by 3rd-party insurers.

52
Incentive Programs

• Incentives can include scholarships, visa waivers
  for IMGs, and tax credits.
• Example
• The Georgia Rural Physician Tax Credit (Georgia
  Department of Revenue Regulation 560-7-8-20)
  provides a tax credit to primary care physicians
  and general surgeons in Georgia who primarily
  admit patients to a rural hospital and reside in
  a rural county or a county contiguous to the
  rural county in which they practice. The credit,
  which maxes out at 5,000 annually, can be
  claimed for a five-year continuous period.

53
Loan Repayment Programs

• Physician loans may be repaid by state agencies,
  private foundations, physician employers, or some
  combination of all interested groups.
• Example
• The Health Professions Education Foundation
  Orange County Pediatric Specialties Physicians
  Loan Repayment Program is available to physicians
  who have been or are in the process of being
  certified by a member board of the American Board
  of Medical Specialties in a pediatric
  subspecialty.
• An awardee may receive up to 125,000 to repay
  educational debt. Each awardee commits to a
  3-year service obligation to practice as a
  full-time physician providing direct patient care
  to a patient population of at least 50 Medi-Cal
  or Healthy Families members including children
  under age of 5 in Orange County.
• The program is funded by Californias Office of
  Statewide Health Planning and Development.

54
Technical Assistance Programs

• Technical assistance usually involves physician
  recruitment, retention, or practice management
  services.
• Example
• The Bi-State Primary Care Association New
  Hampshire-Vermont Recruitment Center works to
  recruit and retain primary care providers in New
  Hampshire and Vermont with particular emphasis on
  the needs of medically underserved areas and
  populations.
• The Recruitment Center's clients include
  federally qualified community health centers,
  public health practices, rural health clinics,
  and hospital-sponsored and private practice
  groups.
• Since 1994, the Recruitment Center has worked
  with over 100 practices to develop personalized
  recruitment and retention strategies, in addition
  to providing direct candidate referrals.

55
Questions?
56
Acknowledgments

• Thanks to the National Governors Association
  Center for Best Practices for the opportunity to
  address this critical issue.

57
Resources

• American Academy of Pediatrics, Division of
  Workforce and Medical Education Policy
• http//www.aap.org/workforce/
• American Academy of Pediatrics, Committee on
  Pediatric Workforce (COPW)
• http//www.aap.org/copw/
• American Academy of Pediatrics, Division of State
  Government Affairs
• http//www.aap.org/advocacy/stgov.htm
• stgov_at_aap.org
• 1-800-433-9016, x7799
• American Academy of Pediatrics, state chapter
  links
• http//www.aap.org/member/chapters/chapters.htm
• American Academy of Pediatrics, oral health
  initiatives
• http//www.aap.org/oralhealth
• oralhealth_at_aap.org

The federally funded Health Workforce
Information Center (http//www.hwic.org/) also
provides excellent health workforce information.
58
Mary Ellen Rimsza, MD, FAAP Chair, Committee on
Pediatric Workforce American Academy of
Pediatrics Professor of Pediatrics, University of
Arizona College of Medicine mrimsza_at_aap.net