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Pediatric Workforce Shortages:

Policy and Advocacy Challenges


Overview: The Pediatrician Workforce

 The general pediatrician pipeline

 Pediatric subspecialty shortages

 Potential solutions

 Questions?
General Pediatricians
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.
YEARS of Formal Education
(at Time of Completion)

General
pediatricians

Pediatric
subspecialists
How Many General Pediatricians Are
There?

Total Active Male Female Board- Non-Board-


(2009) Certified Certified

58,194 24,301 33,893 43,972 14,222

 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.

Source: Physician Characteristics and Distribution in the


US, 2011 Edition (American Medical Association)
State Pediatrician-to-Population Ratios
(# of children for each general pediatrician)

Alabama 2,229:1 Kentucky 2,514:1 North Dakota 2,755:1


Alaska 2,292:1 Louisiana 1,994:1 Ohio 1,815:1
Arizona 2,193:1 Maine 1,717:1 Oklahoma 2,680:1
Arkansas 2,797:1 Maryland 1,143:1 Oregon 2,049:1
California 1,828:1 Massachusetts 1,040:1 Pennsylvania 1,623:1
Colorado 1,966:1 Michigan 2,018:1 Rhode Island 1,227:1
Connecticut 1,220:1 Minnesota 2,234:1 South Carolina 2,220:1
Delaware 1,289:1 Mississippi 2,833:1 South Dakota 3,641:1
DC 484:1 Missouri 1,868:1 Tennessee 1,930:1
Florida 1,605:1 Montana 2,759:1 Texas 2,421:1
Georgia 1,914:1 Nebraska 2,608:1 Utah 2,551:1
Hawaii 1,242:1 Nevada 3,054:1 Vermont 1,236:1
Idaho 4,280:1 New Hampshire 1,577:1 Virginia 1,590:1
Illinois 1,770:1 New Jersey 1,125:1 Washington 2,055:1
Indiana 2,714:1 New Mexico 2,158:1 West Virginia 2,068:1
Iowa 3,004:1 New York 1,068:1 Wisconsin 2,100:1
Kansas 3.300:1 North Carolina 1,895:1 Wyoming 3,077:1
Source: Mapping Health Care Delivery for America’s Children
Project (US Census 2000, AMA/AOA Masterfiles, 2000)
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
Pediatric Subspecialists
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.
YEARS of Formal Education
(at Time of Completion)

General
pediatricians

Pediatric
subspecialists
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 gastroenterology


 Pediatric cardiology  Pediatric heme-onc
 Critical care  Pediatric infectious diseases
 Neonatal medicine
 Child abuse pediatrics
 Pediatric nephrology
 Developmental pediatrics
 Pediatric pulmonology
 Ped emergency medicine
 Pediatric rheumatology
 Pediatric endocrinology
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).
Other Pediatric Subspecialty Training
(years)

“Adult “
residency

Pediatric
subspecialists
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  Pediatric otolaryngology


 Pediatric pathology
 Child and adolescent
psychiatry  Pediatric rehabilitation
 Pediatric radiology
 Pediatric emergency
 Pediatric surgery
medicine
So: How Many Pediatric Subspecialists
Are There?

 Data regarding this question varies, but the most


expansive definition of pediatric subspecialists—which
would include surgical specialists and other specialist
physicians—places 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.
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.


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.
Why Is Pediatric—as Opposed to Adult—
Subspecialty 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
Why Is Pediatric—as Opposed to Adult—
Subspecialty 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).
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).
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.
Subspecialist Supply:
Indicators of a Shortage
Where Do We Find Evidence of
Shortages?

 Wait times for subspecialty appointments

 Difficulty referring to subspecialists

 Difficulty recruiting subspecialists

 Distance to care
Wait Times

Specialty % of Wait times Wait times


 In 2010, the National hospitals (business (weeks)
over 2- days)
Association of Children’s week
Hospitals and Related benchmark

Institutions (NACHRI) reported Endocrinology 68% 51.4 10.3

on the number of weeks Neurology 61% 47.6 9.5


patients had to wait to obtain
subspecialty appointments. Gastroenterology 59% 26.5 5.3

Nephrology 52% 33.6 6.7

 For 10 subspecialties, patients Developmental 50% 65.7 13.1


Pediatrics
had to wait longer than 5
Pulmonology 50% 40.7 8.1
weeks.
Rheumatology 36% 31.9 6.4

 For 3 subspecialties, patients Orthopedics 34% 38.2 7.6

had to wait longer than 10 Dermatology 32% 66.0 13.2


weeks.
Urology 30% 35.2 7.0
Reproduced from NACHRI, Pediatric
Subspecialty Shortages Affect Access to Care
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.
% 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. 2010;156:1011-1015.
Difficulty Recruiting

Subspecialty Percentage of Percentage of Percentage of


Organizations Organizations Positions Being
Recruiting Reporting Medium to Recruited for 6
High Difficulty in Months or More
Recruiting
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”.
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
Mean Distance to Care

Pediatric Subspecialty: Distance to Care (miles):


 Adolescent medicine  42
 Critical care medicine  26
 Developmental pediatrics  44
 Neonatal medicine  15
 Neurodevelopment  73
 Pediatric cardiology  22
 Pediatric endocrinology  26
 Pediatric rheumatology  60
 Pediatric sports medicine  78
 Pediatric nephrology  36
 Pediatric gastroenterology  32

Myer ML. Are We There Yet? Distance to care and relative supply among pediatric
medical subspecialties. Pediatrics. 2006;118:2313-2321.
Percentage of children who must travel
> 80 miles to care

Subspecialty: Percentage of U.S. Children:


 Adolescent medicine  19
 Critical care medicine  7
 Developmental pediatrics  20
 Neonatal medicine  4
 Neurodevelopment  26
 Pediatric cardiology  7
 Pediatric heme/onc  8
 Pediatric endocrinology  11
 Pediatric rheumatology  24
 Pediatric sports medicine  30
 Pediatric gastroenterology  12
 Pediatric nephrology  16
Myer ML. Are We There Yet? Distance to care and relative supply among
pediatric medical subspecialties. Pediatrics. 2006;118:2313-2321.
31
Subspecialty Supply: Contributing
Factors to a Shortage
What Factors Contribute to Subspecialty
Shortages?

 Geographic maldistribution

 Low payment to debt ratio

 Mechanism of financing GME


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. 2009;44:483-495.
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. 2009;44:483-495.
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. 2009;44:483-495.
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. 2009;44:483-495.
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. 2009;44:483-495.
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. 2009;44:483-495.
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. 2009;44:483-495.
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. 2009;44:483-495.
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. 2009;44:483-495.
Trends in Average Educational Debt Among
Graduating Pediatric Residents

Source: AAP Graduating Resident Survey, 1997-2010. Numbers in $2010; includes spousal debt.
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 children’s 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.
Working toward
Solutions
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.
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.
State Success Stories and
Solutions
Models

 General pediatricians fill some gaps.

 Other successful models include:

 Incentive programs
 Loan repayment programs
 Technical assistance programs.
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
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.
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.
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 California’s Office of Statewide Health
Planning and Development.
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.
Questions?
Acknowledgments

 Thanks to the National Governors Association Center


for Best Practices for the opportunity to address this
critical issue.
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@aap.org
 1-800-433-9016, x7799
The federally funded Health
Workforce Information Center
 American Academy of Pediatrics, state chapter links (http://www.hwic.org/) also
provides excellent health
 http://www.aap.org/member/chapters/chapters.htm workforce information.

 American Academy of Pediatrics, oral health initiatives


 http://www.aap.org/oralhealth
Mary Ellen Rimsza, MD, FAAP
Chair, Committee on Pediatric Workforce American
Academy of Pediatrics
Professor of Pediatrics, University of Arizona College of
Medicine
mrimsza@aap.net