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