Hawaii Physician Workforce What are the facts?



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Hawaii Physician Workforce
What are the facts?

Where are we headed?

What can we do?
In accordance with Act 18, SLH, 2009

A report to the 2011 Hawaii State Legislature:

Findings from the Hawaii Physician Workforce Assessment Project

Prepared by:

John A. Burns School of Medicine

Area Health Education Center

December 2010

Forward

The purpose of Act 18, SLH, 2009 is to “implement statewide physician workforce assessment and planning.” It builds on work begun by Act 219, SLH, 2007 and has resulted in: 1) A secure database of non-military practicing physicians in Hawaii; 2) Identified supply/demand gaps; 3) Projections of physician supply and demand through 2020; and 4) Development of a plan to mitigate the supply/demand imbalances. 

The results of this study demonstrate a current shortage of 600 physicians (more than 20% of our total supply) and an impending shortage of 1,600 by 2020. Because physician shortages of the magnitude described will directly impact the health and well-being of virtually all residents of Hawaii, something must be done. Unfortunately, there is NO easy fix to the problem. If we are to overcome this growing shortage, all sectors of society must play a part. Ten actions are described in this document as the first steps and the researchers strongly advise that they be implemented as soon as possible in order to have a chance of mitigating severe shortages.

The researchers would like to acknowledge the Hawaii State Legislature and Hawaii State Board of Medical Examiners for their foresight in appreciating the potential seriousness of the physician shortage problem and providing the funds to bring us to this point. We respectfully submit this report to the 2011 Legislature.

Kelley Withy, MD, PhD David T. Sakamoto, MD, MBA

Researchers, John A. Burns School of Medicine Area Health Education Center (AHEC)

Executive Summary


While anecdotal reports of physician shortages in Hawaii have long been entertained, there are now hard data that show that we currently have a shortfall that exceeds 600 physicians, when compared with a community of the same size on the mainland. Hawaii needs over 200 additional adult primary care providers and is particularly short of Neurosurgeons, Cardiologists, Infectious Disease specialists and General Surgeons. Geographically, although the problem is most acute on Hawaii Island, residents throughout the state are beginning to experience problems accessing physician services.
Our statistical supply-demand model indicates that if significant changes are not made soon in the medical care delivery system, our recruitment and retention effectiveness and the number of doctors that are trained in-state, Hawaii will have a shortage of over 1,600 physicians by 2020. The imbalances are driven principally by population growth and aging, combined with the anticipated loss of over 40% of our practicing physicians to retirement.
In order to mitigate the shortage problem, ten interventions have been prioritized by Hawaii healthcare experts and stakeholders. They include investing in pipeline activities that get more local students into healthcare careers, expanding medical training that addresses geographic distribution and specialty needs, enhancing incentives for physicians to practice on the neighbor islands, involving communities in the recruitment and retention of physicians, creating a more favorable physician practice environment through tort reform, administrative simplification and reimbursement changes and moving the model of care toward a team-based “patient-centered medical home” integrated delivery system that will allow a much smaller physician workforce to care for a larger and older Hawaii populace. The extent of changes needed is very challenging and can only be achieved if all sectors of society (physicians, healthcare administrators and personnel, government, insurers, educators, business and the community) work together to create changes that increase the supply of practicing physicians and decrease the demand for healthcare services in Hawaii.
Hawaii Physician Shortage: Only a Neighbor Island Problem?

We have a shortage of over 600 physicians in Hawaii today, a gap that exceeds 20% of the total physician workforce. The problem is most acute on the Big Island, but people everywhere, including urban Oahu, are also starting to feel the effects in a variety of specialties.



Table 1. Physician Shortage by Island, 2010

Island

Supply

Demand

Shortage

Big Island

313

487

174

Kauai

136

183

47

Lanai

0.4

5

4.6

Maui Island

268

375

107

Molokai

11

16

5

Oahu

2130

2461

331

Total

2858

3527

669

Please see Appendix A for island-specific estimates by specialty.



To gain a perspective on the magnitude of the problem, consider the following: If one were to add up all of the physicians who work within our two largest medical groups, Straub and Kaiser, the total would be fewer than 500 physicians.

What are the Facts?

Supply:

As of December 2010, approximately 2,860 full time equivalents (FTE) of non-military physicians provide patient care services in Hawaii. Although more than 8,300 physicians are licensed to practice medicine in our state, only about a third actually provide patient care services here. The specialties that are more than 20% short are listed below.



Table 2: Hawaii Statewide Physician Deficit: Specialties in Greatest Need

Specialty

Supply

Demand

Shortage

% short

Neurological Surgery

10.4

24

13.6

57%

Pediatric Cardiology

4.0

8.0

4.0

50%

Cardiology

61.4

107

45.6

43%

General Surgery

73.1

125

51.9

42%

Infectious Disease

17.2

29

11.8

41%

Neurology

32.9

53.8

20.1

39%

Gastroenterology

47.1

76

28.9

38%

Endocrinology

15.6

25

9.4

38%

Pulmonary

28.8

45.6

16.8

37%

Thoracic Surgery

18

27.6

9.6

35%

Anesthesiology

147.3

226

78.7

35%

Medicine/Med Peds

388.7

575.7

187

33%

Diagnostic Radiology

130.9

186

55.1

30%

Urology

35

49.6

14.6

29%

Rheumatology

14.8

14

4

29%

Neonatology

15.8

22

6.2

28%

Otolaryngology

31.6

44

12.4

28%

Oncology/Hematology

31.3

43

11.7

27%

Family Med/General Practice

316.5

404.4

87.9

22%

Refer to Appendix A for a detailed listing of the physicians on each island by specialty. Other specialties with large unmet need that are being researcher further are Radiation Oncology, General Pathology and Pediatric subspecialties.
Demand:

If Hawaii’s utilization of physician services were to match the average mainland usage, our current demand for physicians would be about 3,500. If our population grows as anticipated and no changes are made in the system of care or current utilization patterns, our state will need over 4,000 doctors by the year 2020. More in-depth analyses are provided in Appendix C, where different health care scenarios are postulated.

Combining all of the factors included in the research, the best estimate of supply and demand is displayed in the figure below:

Figure 1: Hawaii Physician Supply and Demand Projections


>600

Demand



What is Causing the Physician Shortage?
The Hawaii population is expected to grow from 1.21 million to 1.55 million between 2000 and 2030, a 28% increase.1 Furthermore, the Hawaii population is aging at a rapid rate. During this same period of time, the number of Hawaii residents age 65 and older is projected to double.

Figure 2: Population Aging and Growth in Hawaii1

This is significant because the 75 and over age group uses more than three times the physician services as the under 65 population.2 Therefore Hawaii’s utilization of physician services will be rising significantly faster than it has in the past.



Figure 3: Use of FTE Patient Care Physicians per 100,000 Population3

Unfortunately, our doctors are getting older, too. Across the U.S, 29% of the physicians are 55 years of age or older. However, in Hawaii, 41% of our physicians are 55 or older and will reach retirement age during the coming decade (Figure 4). According to the Association of American Medical Colleges (AAMC), Hawaii has the 5th oldest physician workforce of all the states (percent of practicing physicians 60 and older) and the 6th smallest percentage of young physicians (practicing physicians under 40). 4 Taken together, Hawaii is in the least advantageous position of all the states.


Figure 4: Comparison of proportionate ages of US and Hawaii Physicians5

When examined more closely, many of our specialties are particularly in jeopardy when the ages of the providers are examined.



Figure 5: Hawaii General Surgeons by Age Group
Figure 6: Hawaii Cardiologists by Age Group
Half of our cardiologists will be retirement age by 2020 and we are not attracting nearly enough to replace them. Fortunately, a Cardiology training program has been established in Hawaii this year, educating two cardiologists annually, but this will not solve the current severe shortage of 45 cardiologists.
Concurrent with these demographic trends, the U.S. has simply not trained enough physicians to keep up with our growing needs. In the late 1990’s when the prevailing sentiment was that there would be a large physician surplus, the number of physicians trained annually was capped at the 1996 level. This federal restriction was not relaxed until 2009. It is now recommended that medical schools increase their class size by 20-30%.6 However, due to the length of medical training (11 years for a primary care doctor and 15 years for a neurosurgeon), this impact will not be felt for many years. There are several other factors that affect the physician workforce, including productivity, employment opportunities and generational trends. A discussion of these is included in Appendix B.
What Will This Mean for Healthcare in Hawaii?

In the context of a deepening national physician shortage, simply maintaining the current annual inflow will be challenging. As stated earlier, despite active recruitment activities, Hawaii will probably suffer a net loss of 50 physicians every year in the face of dramatically rising demand.

If the delivery system remains the same as today, many Hawaii residents will not have timely access to care.  Newcomers, the indigent and the elderly will feel it first.  As the shortage deepens, we’ll all experience the effects.  Harried PCPs will spend precious little time with each patient, focusing primarily on immediate acute problems.  Preventive care, health screening, early diagnosis and even physician job satisfaction will be triaged to the sideline.  Our emergency rooms will be over-flowing, our hospitals will be running at above 100% occupancy and the costs will be staggering. 

This scenario is clearly unacceptable.  Before we reach this point our health insurers will most likely be compelled to approach large physician groups on the mainland to contract for services.  These groups would hire physicians and send them to Hawaii to provide medical care.  The quality of the people they send will probably depend on how much we’re willing to pay and it would be very expensive


On the other hand, if appropriate changes are made in our healthcare delivery system, a smaller physician workforce will be able to adequately care for a larger, older Hawaii population. Mainland healthcare organizations have shown that physicians, when practicing within an integrated delivery system such as the Mayo Clinic or the Geisinger Health System, can care for many more people, while generating better quality outcomes at lower costs. Moreover, in these team-based “integrated delivery systems” both the patients and the physicians have higher levels of satisfaction.7

The predictions discussed are based on the health care system remaining as it is today. Many variables can change. For example, if there are advances in medical science that cure chronic disease, demand will decrease. Increasing medical insurance coverage will increase demand, especially for primary care services. If the primary care provider shortage continues, much of the initial care of patients will be shifted to emergency departments, driving up both demand for Emergency Physicians and cost of care.8


Why is the Physician Shortage Hard to Fix?

Every state is facing the same demographic trends as Hawaii, making physician shortages a national phenomenon. Each doctor in a shortage specialty will be highly sought after, making it harder and harder for Hawaii to recruit. The most common barriers to recruitment and retention are listed in Appendix D and have to do with incentives, practice environment and family needs. Efforts to retain physicians are complicated by the fact that many of the doctors who move here from elsewhere never fully assimilate into the community or do not find the medical groups, jobs or schools they expected. Many have overriding family concerns or leave for better income potential on the mainland. The physicians most likely to stay in Hawaii long term are the ones who grew up in and/or trained in Hawaii.


Training:

Currently 74 medical students and between 75 and 80 residents are trained in Hawaii each year. Due to the number of years required to train a physician (11 to 15 years), we cannot simply “train our way out of the problem.” However, it is far easier to recruit a physician trained in-state. About half of all John A. Burns School of Medicine (JABSOM) graduates practice in Hawaii and more than 80% of JABSOM graduates who also complete a residency training program here will practice in Hawaii. Therefore if we can expand the training for local students and target it to our specific needs we will maximize the benefit of our medical educational system and are likely to retain more of our local providers. For example, if we need more primary care physicians in Hilo, then we should select more qualified students from Hilo and provide much of their primary care training in Hilo.


Unfortunately, expanding our medical training capacity will require a substantial amount of funding and the federal government only pays part of the cost. Because Hawaii is a small state with limited clinical teaching resources, we will never be able to train the entire scope of specialists that are needed. Therefore we must look to complementary solutions to the physician workforce shortage.
Enticements:

Enticements such as loan repayment, tax incentives, effective malpractice reform and supportive networks have not been widely adopted in Hawaii. In addition, a majority of young physicians are looking for an employment situation, rather than a private practice opportunity that entails more financial risk. In Hawaii, we have a large percentage of solo and small group practitioners, and limited physician job opportunities. Some feel that the solo practice/small group structure of our delivery system, where few have the ability to offer employment positions, is the most notable reason Hawaii is not attracting young physicians.


Productivity:

If we can’t increase the supply of physicians fast enough, then we can only hope to mitigate the damage by increasing system-wide productivity and decreasing unnecessary care. Interventions such as Electronic Health Records, creating care teams with non-physician clinicians and striving for administrative simplification (less paperwork, fewer billing/payment obstacles and more reasonable procedures for obtaining authorization for diagnostic tests or surgery) have been successfully implemented in other states, but have met resistance in Hawaii.


Because of the doctor shortages, the traditional model of care delivery will have to change. Best case scenario is that medical teams composed of a range of health professionals from home caregivers to neurosurgeons must work together to provide the care we need. Ideally, we will all have timely access to a primary care provider via a Patient Centered Medical Home, where our medical records will be kept in electronic form, where we will receive individualized care by providers that we know and trust, where referrals to specialists or for tests will be tracked and where we can expect consistent follow up care.
Solutions to act on now:
The solutions tend to fall along two lines: 1) growing the physician workforce by optimizing our recruitment and retention activities and expanding our training; and 2) transforming the delivery system so that a smaller physician workforce will be able to adequately care for an older and larger Hawaii population. The researchers emphasize that both must be successfully achieved within a relatively small window of time.
An extensive literature review, fourteen focus groups and interviews with local healthcare experts were completed across the state to identify potential solutions to the physician shortage. More than 50 interventions were uncovered with responsibilities that could be allocated to physicians, hospitals, insurance companies, businesses, education, government and communities. The researchers urge the interested reader to examine Appendix E for details.
Because there are so many solutions, assistance was needed to identify the ones to engage in first. In June, 2010, the John A. Burns School of Medicine hosted the Hawaii Physician Workforce Summit. A total of 144 policy makers, administrators, health professionals and stakeholders spent the day prioritizing potential solutions. A brief summary is included at the end of Appendix D and the presentations and documents from this meeting are available at www.ahec.hawaii.edu/workforce.html. The ten priority steps identified at the summit are listed in Table 3 below.
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