Wisconsin Primary CarePhysicians

Current Distribution and Retirement Projectionsusing

Wisconsin Health Service Areas Geography

Nancy SugdenDirector, Wisconsin AHEC ProgramAssistant Dean, Academic Affairs

University of Wisconsin School of Medicine and Public Health

Presented 3-23-15Updated 6-12-15

Part I:Wisconsin Primary Care

Physician Distribution

3

Framework for Analysis: Wisconsin Health Service Areas

•135 service areas•17 regional groups

• 6-7 types:metro, metro/academic, urban,mixed (hub>10,000), mixed (hub<10,000),rural (hub 2500-10,000), rural (hub<2500)

4

Data Sources• Data 3-15-2012 for 21,604 physicians (MD and DO)

licensed in Wisconsin as of 9-1-2011. 14,722 ofthese (excluding trainees) have address of record inWI.

• Survey data from approximately 30% of thesephysicians via relicensure survey conducted October2011-February 2012, weighted for age, sex, specialtyand location (urban-rural).

• Information about work setting and hours of work inpatient care from the survey.

5

The physician licensure record

Available data in electronic format includes– name– license type and license status (not practice status)– date of first licensure in Wisconsin– year of birth– gender– location (DSPS mailing address) - city, state and zipcode– degree (MD or DO)– degree date– degree granting institution– practice specialty

6

• If we are unable to do a re-licensure surveycompleted by all physicians, then what mightwe be able to discover from the availablelicensure data alone, using the WisconsinHealth Service Areas as a framework?

• working from the data set of 3-15-2012,drawn at the conclusion of the 2011-12 MDand DO relicensure cycle.

7

Key assumptions:1) For physicians under 65, the DSPS address most likely

reflects the service area, if not the specific location, in whichthey are practicing.

2) Physicians under 65 who have maintained their license are stillactive as physicians, whether in patient care, administration,teaching or research.

Comparison to responses from the 2011-12 survey supportsthese assumptions with a few caveats: physicians traveling tomany locations to practice (psychiatrists), physicians travelingfrom metro areas to outlying service areas for part-timepractice.

8

Population to Physician Ratioby type of service area

WI-based physicians under age 65 as of 1-1-2012Location is address of record with DSPS as of 3-15-2012

12,544 Wisconsin-based physicians

5,686,986274,588

775,372

211,040

183,612

555,454

2,990,740

696,180

Population

12,544260

607

289

255

673

7056

3404

All Physiciansunder age 65

453:11056:1

1277:1

730:1

720:1

825:1

424:1

205:1

Ratio

Academic

STATEWIDERural-Hub<2500

Rural-Hub ≥2,500

Mixed-Hub <10,000

Mixed-Hub ≥10,000

Urban

Metro

Service Area Type

9

Maldistribution or overall shortage ofphysicians?

• Subspecialties, surgeons and facility-basedspecialties (anesthesiology, radiology, etc.)will be concentrated in the metro and urbanareas where larger hospital facilities, and willserve an area larger the the services areaswe defined.

• Need to look at specialties that we wouldexpect to be more evenly distributed to meetpopulation needs

10

Identifying Primary Care Physicians

• Primary Care = those who listed generalmedicine, family medicine, internal medicine(without medical subspecialty), geriatrics,pediatrics (without subspecialty) and med-peds

• Includes those who may have listedadministration, research, occupationalmedicine, etc. in addition to one of the primarycare practice specialties above

11

Examples from the licensure record

- Primary care• GENERAL  PRACTICE• FAMILY  PRACTICE• OCCUPATIONAL  MEDICINE|FAMILY  PRACTICE• PREVENTIVE  MEDICINE|FAMILY  PRACTICE• PEDIATRICS• IINTERNAL  MEDICINE• NTERNAL  MEDICINE|OCCUPATIONAL  MEDICINE• INTERNAL  MEDICINE|ALCOHOLISM  -­‐  CHEMICAL  DEPENDEN• INTERNAL  MEDICINE|ACADEMIC  MEDICINE|ADMINISTRATIVE  MEDICINE• INTERNAL  MEDICINE|PREVENTIVE  MEDICINE|PEDIATRICS|ACADEMIC  MEDICINE• INTERNAL  MEDICINE|GERIATRICS

– Not primary care• INTERNAL  MEDICINE|ACADEMIC  MEDICINE|ENDOCRINOLOGY|GENETICS• INTERNAL  MEDICINE|HEMATOLOGY|RESEARCH|ACADEMIC  MEDICINE|ONCOLOGY• INTERNAL  MEDICINE  -­‐  CARDIOLOGY|ACADEMIC  MEDICINE|FAMILY  PRACTICE• HEMATOLOGY|ACADEMIC  MEDICINE|ONCOLOGY|PEDIATRICS  -­‐  OTHER• EMERGENCY  MEDICINE|FAMILY  PRACTICE|ADMINISTRATIVE  MEDICINE• AEROSPACE  MEDICINE|RESEARCH|ACADEMIC  MEDICINE|FAMILY  PRACTICE• PREVENTIVE  MEDICINE|ACADEMIC  MEDICINE• OCCUPATIONAL  MEDICINE• PREVENTIVE  MEDICINE

12

• In developing our protocol for identifyingspecialty from the licensure record alone, wechecked our determination from the licensurerecord against information about practicespecialty and hours of work from respondentsto the survey.

13

Eliminating trainees from the data setIn 2011-12, many trainees completed a survey, so could tellfrom that information.However, if you didn’t have the survey information you could stillget there . . .– Licensure record includes date of graduation and date of first

licensure in Wisconsin.– All physicians less than 3 years post graduation are assumed to be

in residency training positions.– Other specialties have longer training periods - use the length of

training period to eliminate.– Still have issue with group going into subspecialty medicine or

pediatrics who could be in training up to 6 years post-graduation -not always identified as subspecialty in the licensure record.

• We know how many residents there are in each PG year, and where they are,from ACGME data.

• We know when the data was drawn (best if before March when next group of PG-1s begin applying for residency.)

• Use information about how many there should be in each service hub, andeliminate that number from the service area total, taking youngest first.

14

15

Population to Primary Care Physician Ratioby type of service area

WI-based physicians under age 65 as of 1-1-2012Location is address of record with DSPS as of 3-15-2012

Specialty as indicated on DSPS data as of 3-15-2012: general practice,family medicine, general internal medicine, pediatrics, geriatrics

(does not include those who listed a medical subspecialty)5058 primary care physicians

453:11056:1

1277:1

730:1

720:1

825:1

424:1

205:1

All Physiciansunder age 65

653:1Academic

1124:1STATEWIDE1795:1Rural-Hub<2500

1803:1Rural-Hub ≥2,500

1206:1Mixed-Hub <10,000

1360:1Mixed-Hub ≥10,000

1639:1Urban

1084:1Metro

Primary CarePhysicians under

age 65 only

Service Area Type

16

Population to Primary Care Physician<age 65,by region

5,686,986 pop

381,489

114,310

69,465

174,159

352,965

290,009

66,166

246,150

667,420

469,599

274,040

1,328,682

172,043

162,242

293,325

196,867

428,055 population

5058 physicians

413

87

42

115

313

328

24

158

813

234

239

1414

108

109

244

116

301 physicians

1124:1STATEWIDE

924:1Wausau

1314:1Rhinelander

1654:1Superior

1514:1West Central

1128:1Eau Claire

884:1La Crosse

2757:1Southwest

1558:1Janesville

821:1Madison

2007:1Southeast

1147:1Waukesha

940:1Milwaukee

1593:1Fond du Lac

1488:1Oshkosh

1202:1Appleton

1697:1Sheboygan

1422:1Green Bay

17

Primary CarePhysiciansPopulation to

primary carephysician ratios

Primary care physicians < age65 as of 1-1-2012

Assumes address of recordwith DSPS as of 3-15-2012 reflects service areawhere practice is located

18

Adjusting for office-based primarycare FTE

Primary care physicians not providing anypatient care

Other responsibilities of patient carephysicians: administration, teaching, research

Non office-based patient care timePart-time work by physicians 65 and olderPatient care provided in person in WI by

physicians from IL, IA, MN, MI

19

First steps primary care physicians not providing any

patient care other responsibilities of patient care

physicians– administration– teaching– research

non office-based patient care time– hospitalists– emergency room– facility-based primary care (nursing homes, extended care

facilities, prisons)

20

Use data from the survey on hours ofpatient-related care

Q45  During  the  weeks  that  you  worked  in  the  past  year,  how  many  hours  perweek,  on      average,  did  you  spend  on  pa9ent-­‐related  care*  at  all  loca9onswhere  you  prac9ce  in  Wisconsin.    Include  on-­‐call  9me  only  to  the  extent  youwere  actually  engaged  in  pa9ent  care  or  coordina9on.

Hours  per  week__Hospital  inpaFent  care__Emergency  room__Primary  care**  in  the  office/outpaFent  seOng__Specialty  care  in  the  office/outpaFent  seOng__Telemedicine  consults__Seeing  paFents  in  nursing  homes  and  other

non-­‐hospital  extended  care  faciliFes__Seeing  paFents  in  their  own  homes__Seeing  paFents  in  correcFonal  faciliFes__All  other  paFent-­‐related  care  acFviFes__TOTAL

21

Non-patient careQ48    Are  you  involved  in  any  of  the  following  professional  ac9vi9es?

(check  all  that  apply)• Research• Teaching-­‐classroom• Teaching  –  clinical  seOng• AdministraFon  in  a  private  pracFce• AdministraFon  in  a  medical  school,  hospital,  health  plan  ornursing  home

• Medical  examiner• Board  of  health• Medical  adviser  to  other  public  or  community  agency• Other  (specify)• None  of  the  above

Q  49    During  the  previous  twelve  months,  about  how  many  hours  per    week,  on  average,  did  you  spend  in  all  these  other  professionalac9vi9es?

22

Definitions used with hours of work question:

• *Patient-related care includes clinical practice, related office work,communications with hospitals/physicians regarding patients andother related activities.

• **Primary Care is defined as providing first contact and continuingcare, including basic or initial diagnosis and treatment, healthsupervision, management of chronic conditions, preventive healthservices, and appropriate referral(s).

23

24

Adjustments to estimated office-based primary carepatient care physician FTE

(Estimates based on 2011-12 Wisconsin Physician Re-licensure Survey)

4662

131

401

146

129

321

2564

970

Est. numberpatient careprimary carephysicians < age65

23.8%

19.9%

10.6%

10.7%

30.8%

13.4%

23.5%

34.8%

Estimated %primary care ptcare physicianswho do not have anoffice-basedpractice

3555

105

359

131

89

278

1961

633

Est. numberoffice-basedprimary carephysicians <age 65

5058

153

430

175

135

339

2760

1066

Primary carephysiciansunder age 65as of1-1-2012

Estimated %primary carephysicians whodo not have apatient practice

Service AreaType

7.8%

14.5%

6.7%

16.5%

4.6%

5.3%

7.1%

9.0%

STATEWIDE

Rural-Hub<2500

Rural-Hub ≥2500

Mixed-Hub< 10,000

Mixed-Hub ≥10,000

Urban

Metro

Academic

25

WI Primary Care Physicians<age 65with office-based primary care practice

Allocation of time, by type of service area(2011-12 Wisconsin Physician Re-licensure Survey)

3555

105

359

131

89

278

1961

633

Est. numberoffice-basedprimary carephysicians

5.6 hrs2.7 hrs5.1 hrs1.1 hrs37.0 hrs51.7 hrsSTATEWIDE

4.6 hrs1.0 hrs15.7 hrs1.1 hrs34.9 hrs57.3 hrsRural-Hub <2500

3.6 hrs2.6 hrs8.3 hrs3.3 hrs36.2 hrs54.0 hrsRural-Hub >2500

3.5 hrs2.5 hrs6.5 hrs1.2 hrs37.3 hrs51.0 hrsMixed-Hub < 10,000

6.8 hrs1.5 hrs3.9 hrs0.7 hrs38.2 hrs51.2 hrsMixed-Hub >10,000

3.9 hrs2.3 hrs7.0 hrs1.0 hrs38.4 hrs52.5 hrsUrban

4.5 hrs2.7 hrs3.9 hrs1.0 hrs38.4 hrs50.6 hrsMetro

10.9 hrs3.4 hrs4.5 hrs0.9 hrs33.0 hrs 52.6 hrsAcademic

Admin,research,teaching, othernon-patient care

Specialty& otherpatientcare

Inpatient& ER

Long-term care,home visits,corrections

Office-basedprimary care

Totalaveragehrs/wk

26

Summary: statewide estimate ofoffice-based primary care physicians

• 3381 primary care physicians < age 65 reportingmajority of time in office-based primary care practice

• 174 other primary care physicians < age 65providing some office-based primary care

• 3555 total primary care physicians < age 65 providingoffice-based primary care practice, provide onaverage 37 hrs/wk of office based pt care

• 1600:1 statewide pop. to office-based patient careprimary care provider under 65 with DSPS address inWisconsin

• 1725:1 if standardized to 40 hrs/wk FTE office-basedpatient care FTE

27

Estimate by Service Area TypeRatio used for service areas to estimate office-based primary care FTE in

each service area

37.0 hrs/wk

34.9 hrs/wk

36.2 hrs/wk

37.3 hrs/wk

38.2 hrs/wk

38.4 hrs/wk

38.4 hrs/wk

33.0 hrs/wk

Avg. office-based patientcare hours perweek

1.535555058STATEWIDE

1.7 105153Rural-Hub <2500

1.3 359430Rural-Hub >2500

1.4 131175Mixed-Hub < 10,000

1.6 89135Mixed-Hub >10,000

1.3 278339Urban

1.519612760Metro

2.0 6331066Academic

PC physiciansper 40 hr FTEoffice-basedprimary care

Est. # primary carephysicians withoffice-based primarycare practice

All primarycarephysicians<65as of 1-1-2012

28

Office-based primary care physicianhours

9.0 hrs

17.8 hrs

14.2 hrs

10.2 hrs

6.1 hrs

10.2 hrs

7.6 hrs

8.6 hrs

Otherpatientcare

5.6 hrs

4.6 hrs

3.6 hrs

3.5 hrs

6.8 hrs

3.9 hrs

4.5 hrs

10.9 hrs

Non-patientcare

37.0 hrs/wk

34.9 hrs/wk

36.2 hrs/wk

37.3 hrs/wk

38.2 hrs/wk

38.4 hrs/wk

38.4 hrs/wk

33.0 hrs/wk

Avg. office-basedpatient carehours per wk

51.7 hrs3555STATEWIDE

57.3 hrs 105Rural-Hub <2500

54.0 hrs 359Rural-Hub >2500

51.0 hrs 131Mixed-Hub < 10,000

51.2 hrs 89Mixed-Hub >10,000

52.5 hrs 278Urban

50.6 hrs1961Metro

52.6 hrs 633Academic

Totalhours

Est. # primary carephysicians withoffice-based primarycare practice

29

Estimated office-basedprimary care patientcare ratios

Population to physician ratio3555 office-based primary care physicians= 3297 FTE physicians if 1 FTE = 40 hrs

office-based patient care1725:1 statewide ratio

Primary care physicians < age 65 asof 1-1-2012

Assumes address of record withDSPS as of 3-15-2012 reflectsservice area where practice islocated

Estimation of office-based primarycare FTE based on 2011-12Wisconsin Physician Re-licensureSurvey

30

Office-based Primary CareStandardized to 40 hr/wk FTEAll Primary Care Physicians

31

Federal shortage area ratios

• 2000:1 is the standard HRSA uses forcalculating the number of practitionersneeded for removing primary care physicianshortages. If an area is >2000:1, thepractitioners cannot be expected to alleviatea shortage in an adjacent area.

• 3500:1 (3000:1 under certain circumstances)is the standard for a severe shortage,qualifying for a HPSA designation.

32

Shortage areas

• Revised map comparingcurrent shortagedesignations to areas with>3000:1 population toestimated 40 hour/FTEoffice-based primary carephysician

• 6 areas between 3000 and3500:1 (Osseo, Shell Lake,Darlington, Sparta, NewLondon, New Glarus)

• 33 areas over 3500:1(remainder of those shadedon the map)

33

Differences in the calculation• We include NHSC physicians and non-citizen foreign

medical graduates. These are excluded from thefederal calculations.

• We do not include residents (counted at 0.1 in thefederal calculation). This would be a factor only inservice areas where residents are present (not many,outside the metro areas).

• We do not include OB-Gyn physicians in the primarycare count. They would be included in the federalcalculation, to the extent they provide office-basedprimary care services.

34

Adjusted ratio >2000:1 Original map with unadjusted ratio>1500:1

35

Further adjustments• Part-time work by physicians 65 and older

– about 219 (41%) of licensed primary care physicians over age 65have an office based practice (varies from 23.6% to 54.7% byservice area type)

– those 219 provide on average 25.7 hrs/wk of office-based primarycare

• Patient care provided in person in WI by primary care physicians fromIL, IA, MN, MI– estimate 62 primary care physicians with address in neighboring

states are providing patient care in person in WI– those 62 provide on average 29.7 hrs/wk of office-based primary

care in the affected communities

36

Population to Primary Care Physicianby service area type, as adjusted:

1600:12622:1

2161:1

1617:1

2059:1

1998:1

1525:1

1100:1

III. Adjustedto includeoffice-basedprimary carepatient careonly

1725:13005:1

2391:1

1735:1

2150:1

2080:1

1587:1

1332:1

IV. Adjusted toreflect primarycarephysicians per40 hr FTEoffice-basedprimary care

1220:12099:1

1933:1

1444:1

1426:1

1730:1

1166:1

718:1

II. Adjusted toincludeprimary carepatient carephysiciansonly

1290:1 653:1Academic

1124:11795:1

1803:1

1206:1

1360:1

1639:1

1084:1

I. Unadjustedpopulation toPC physicianunder age 65

1647:1STATEWIDE2918:1Rural-Hub<2500

2241:1Rural-Hub≥2500

1612:1MixedHub<10,000

1873:1MixedHub≥10,000

2017:1Urban

1519:1Metro

V. Adjusted toinclude non-WI physiciansand WIphysiciansover age 65

Service Area Type

37

Back to the original question: Maldistributionor overall shortage? . . . . your time is up

86 minutesAcademic

67 minutesSTATEWIDE

38 minutesRural-Hub<2500

48 minutesRural-Hub≥2500

66 minutesMixed-Hub<10,000

54 minutesMixed-Hub≥10,000

55 minutesUrban

73 minutesMetro

Estimated minutes per capita per year of office-based primarycare for population in the service area, assuming 48weeks/year/office-based primary care physician

Service Area Type

Part IIPrimary Care PhysicianRetirement Projections

3-23-15

39

Data Sources• Data 3-15-2012 for 21,604 physicians (MD and DO)

licensed in Wisconsin as of 9-1-2011. 14,722 ofthese (excluding trainees) have address of record inWI

• Survey data from approximately 30% of thesephysicians via relicensure survey conducted October2011-February 2012, weighted for age, sex, specialtyand location (urban-rural)

• Information about work setting and hours of work inpatient care from the survey

40

Framework for Analysis: Wisconsin Health Service Areas

•135 service areas•17 regional groups

• 6-7 types:metro, metro/academic, urban,mixed (hub>10,000), mixed (hub<10,000),rural (hub 2500-10,000), rural (hub<2500)

41

How do we know whenphysicians will retire?

• Licensure record includes an option for“retired” under specialty, but evenphysicians without a regular patientcare practice don’t tend to check thatwhen they area renewed their license.

42

43

How do we know whenphysicians will retire?

• Can we make any generalizations fromthe survey data we have from 2011-12?

44

Questions on the surveyRetirement plans:

 Q42a  How  much  longer  do  you  plan  to  maintain  a  pa7ent  care  prac7ce?1=Less  than  2  years,  2=2-­‐5  years,  3=6-­‐10  years,  4=11-­‐15  years,  5=16-­‐20   years,  6=21-­‐25  years,  7=26-­‐30  years,  8=more  than  30  years

Or, alternatively  Q42b  At  what  age  do  you  plan  to  re7re  from  your  pa7ent  care  prac7ce?    _____

Current status:Q1    What  is  your  current  status?

1=pt  care  in  WI,  2=in  WI  but  no  pt  care,  3=pt  care  only  outside  WI,4=not  working  as  physician

Q33 Are  you  currently  ac7ve  in  medicine*?  (check  only  one)1=Yes,  full-­‐Fme  (≥32  hrs/wk)2=Yes,  part-­‐Fme  (<32  hrs/wk),3=No,  not  currently  acFve  in  medicine

*Ac9ve  in  medicine  includes  providing  clinical  services,  conduc9ng  medical  research,  medical  teaching,health  care  administra9on  and  other  professional  medical  ac9vi9es.

45

46

True or False?

1) There will be an increasing proportion ofphysicians reaching retirement just at thetime the population need increases due tothe aging of the “baby boom” generation.

2) The prospect of 30% of physicians retiringover the next decade is cause for alarm.

47

Birth rate, 1909-2009

48

Medical School Graduatesfrom 1983 (born ~1957 during baby boom years)

to 2011 (born ~1985)

49Source: AAMC

50

51

Source: AAMC

52

53

What is the expected retirement ratefor physicians?

• If 35 year career (age 30-65) and an evenage distribution of the workforce, you wouldexpect 10/35ths of the workforce to retireeach decade, or 28.6%.

• Of course, if only a few physicians in aservice area, the retirement of one physicianhas a much larger impact on access to care ifunable to recruit a replacement

54

Primary CarePhysiciansRetirement Projections

75 service areas with>30% reaching 65between 2012 and2021

55

Primary CarePhysicians

Retirement Projectionscompared to currentpop to provider ratio

(base map is populationto primary carephysician beforeadjusting for patientcare, office-basedpractice, etc.)

56

Putting it all together

• Adjusted ratio >2000:1and ten year retirement> 30%

• Remember - this issituation as of January2012 and doesn’t reflectchanges in the lastthree years.

57

Number of primary care physiciansreaching age 65,

by service area type

STATEWIDE

Rural-Hub<2500

Rural-Hub≥2500

MixedHub<10,000

MixedHub≥10,000

Urban

Metro

Hub Type

914773731791554

1829203125

58486010165

3121223526

4541414122

5552595653

707582529527363

2032-20362017-20312022-20262017-20212012-2016

58

Primary Care Disciplines,by service area type

1.1%24.3%45.0%29.5%Academic

1.3%16.4%33.5%48.9%STATEWIDE

1.3%4.6%19.0%75.2%Rural-Hub<2500

0.5%4.2%10.7%84.7%Rural-Hub≥2500

0,6%8.0%21.7%69.7%MixedHub<10,000

0.0%11.1%29.6%59.3%MixedHub≥10,000

0.6%10.9%28.0%60.5%Urban

1.6%17.3%35.0%46.1%Metro

Med-PedsGeneralPediatrics

GeneralInternal

Medicine

Family Medicine &General Practice

Hub Type

59

Primary careretirementrates bydiscipline byservice areatype

60

Primary care retirement as % total primary care,by service area type

61

5 year retirement projections, all primary care compared toexpected 5 yr rate and # residency graduates at current levels

62

Compare retirement projection to current residencyprogram graduates, primary care disciplines

63

How will this projection be affected byother factors?

• Supply:– increase or decrease in age at retirement– decrease in average hours worked (lifestyle

preferences of younger physicians)– increase in GME programs

• Demand:– demographic change - overall population increase

and increase in population over age 65– expanded insurance coverage through the ACA– managed care/medical home/ACO implementation– increased use of advanced practice providers

(APRN and PA)

64

Stay tuned!

65

AcknowledgementsMany thanks to Michael Jacob in the AHEC Program Office

for work on the maps.

For further information, contact:Nancy Sugden

Assistant Dean, Academic Affairs, UWSMPHDirector, Wisconsin AHEC Program

nasugden@wisc.edu

or see the AHEC workforce webpage atwww.ahec.wisc.edu/workforce