kamemoto lori, sood sneha

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Access to Health Care in Hawaii: Access to Health Care in Hawaii: the Pediatric and Obstetrics the Pediatric and Obstetrics Workforce Shortage Workforce Shortage Lori Lori Kamemoto Kamemoto , MD, MPH, FACOG , MD, MPH, FACOG Sneha Sneha Sood, MD, Neonatology; JABSOM Sood, MD, Neonatology; JABSOM 2008 Perinatal Health Summit 2008 Perinatal Health Summit Waikoloa, Hawaii Waikoloa, Hawaii October 24, 2008 October 24, 2008

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Page 1: Kamemoto lori,  sood sneha

Access to Health Care in Hawaii: Access to Health Care in Hawaii: the Pediatric and Obstetrics the Pediatric and Obstetrics

Workforce ShortageWorkforce Shortage

Lori Lori KamemotoKamemoto, MD, MPH, FACOG, MD, MPH, FACOGSnehaSneha Sood, MD, Neonatology; JABSOMSood, MD, Neonatology; JABSOM

2008 Perinatal Health Summit2008 Perinatal Health SummitWaikoloa, HawaiiWaikoloa, HawaiiOctober 24, 2008October 24, 2008

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Workforce Shortage in HawaiiWorkforce Shortage in Hawaii

�� Background and National DataBackground and National Data

�� Hawaii�s Pediatric WorkforceHawaii�s Pediatric Workforce

�� Hawaii�s Obstetrics and Gynecology Hawaii�s Obstetrics and Gynecology WorkforceWorkforce

�� Solutions?Solutions?

Page 3: Kamemoto lori,  sood sneha

ObjectivesObjectives

�� Overview of the healthcare workforce Overview of the healthcare workforce shortage in U.S. and Hawaiishortage in U.S. and Hawaii

�� Discuss challenges in access to health Discuss challenges in access to health care in Obstetrics and Pediatrics on the care in Obstetrics and Pediatrics on the neighbor islandsneighbor islands

�� Discuss possible solutionsDiscuss possible solutions

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Health Care DisparitiesHealth Care Disparities�� HRSA: HRSA: "population"population--specific differences in the specific differences in the

presence of disease, health outcomes, or presence of disease, health outcomes, or access to health careaccess to health care��−− Gaps in the quality of healthcare across racial, ethnic, Gaps in the quality of healthcare across racial, ethnic,

gender, socioeconomic and other groupsgender, socioeconomic and other groups

�� Healthcare disparities wellHealthcare disparities well--documented in U.S. documented in U.S. racial minority groupsracial minority groups−− African Americans, Native Americans and Native African Americans, Native Americans and Native

Hawaiians, Hispanics at higher risk than whites for Hawaiians, Hispanics at higher risk than whites for chronic diseases and cancer, higher mortality, and chronic diseases and cancer, higher mortality, and poorer health outcomespoorer health outcomes

−− Minorities also have higher infant mortality, Minorities also have higher infant mortality, cardiovascular disease and HIV than whitescardiovascular disease and HIV than whites

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Causes of Healthcare DisparitiesCauses of Healthcare Disparities�� EnvironmentEnvironment−− Minorities, on average, live in socioeconomically Minorities, on average, live in socioeconomically

disadvantaged areasdisadvantaged areas�� Example: children�s lead paint exposureExample: children�s lead paint exposure

�� Barriers to Access to careBarriers to Access to care−− Minority groups may have more difficulty accessing Minority groups may have more difficulty accessing

healthcarehealthcare�� Examples: insurance issues, rural areas where there are less Examples: insurance issues, rural areas where there are less

physicians, etc.physicians, etc.

�� Differences in Quality of careDifferences in Quality of care−− Minority groups may be receiving care, however receive Minority groups may be receiving care, however receive

poorer quality of care resulting in different outcomespoorer quality of care resulting in different outcomes�� Example: African Americans with breast cancer have a higher Example: African Americans with breast cancer have a higher

mortalitymortality

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Access to HealthcareAccess to HealthcareBarriersBarriers

�� No health insurance or insurance that limits No health insurance or insurance that limits healthcare services coveredhealthcare services covered

�� No Primary Care Provider, no medical homeNo Primary Care Provider, no medical home�� No money/financial meansNo money/financial means�� Legal barriers: immigrantsLegal barriers: immigrants�� Structural barriers: transportation, inconvenient Structural barriers: transportation, inconvenient

office hours, excessive time in waiting roomoffice hours, excessive time in waiting room�� Language barrier/Health literacyLanguage barrier/Health literacy�� Lack of diversity in the healthcare workforceLack of diversity in the healthcare workforce�� Scarcity of Health Care ProvidersScarcity of Health Care Providers

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Help Wanted: More U.S. DoctorsProjections Indicate America Will

Face Shortage of M.D.s by 2020

Tomorrow�s Doctors, Tomorrow�s Cures®

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Tomorrow�s Doctors, Tomorrow�s Cures®

The United States will face a seriousdoctor shortage in the next fewdecades. Our nation�s rapidly growingpopulation, increasing numbers ofelderly Americans, an aging physicianworkforce, and a rising demand forhealth care services all point to thisconclusion.

Page 9: Kamemoto lori,  sood sneha

AAMC Report AAMC Report �� Many areas of the country and some healthcare Many areas of the country and some healthcare

specialties already reporting a scarcity of specialties already reporting a scarcity of physiciansphysicians

�� Acute national shortage would have a profound Acute national shortage would have a profound effect on healthcare:effect on healthcare:−− Longer wait timesLonger wait times−− Longer travel times for careLonger travel times for care−− Elderly, poor, rural residents, and the 20% who are Elderly, poor, rural residents, and the 20% who are

already medically underserved would be most affectedalready medically underserved would be most affected�� Depending on the specialty, it can take up to 14 Depending on the specialty, it can take up to 14

years from the time education is begun to the years from the time education is begun to the time physician starts practicetime physician starts practice

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Number of Elderly will double by 2030Number of Elderly will double by 2030

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Doctor Visits sharply higher for over 65Doctor Visits sharply higher for over 65

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U.S. has Low Physician to U.S. has Low Physician to Population ratioPopulation ratio

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First Year MD Enrollment per 100,000 First Year MD Enrollment per 100,000 population declining since 1980population declining since 1980

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U.S. MDs TwoU.S. MDs Two--thirds of those thirds of those Entering Residency Training, 2005Entering Residency Training, 2005

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Physician Workforce is AgingPhysician Workforce is Aging250,000 Active MDs are over 55250,000 Active MDs are over 55

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30 million Already Live in Federally 30 million Already Live in Federally designated Shortage Areasdesignated Shortage Areas

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HRSA: 10HRSA: 10--20% Physician 20% Physician Shortage by 2020Shortage by 2020

Increase Supply

Increase Demand

Primary Care 18% 20-30%Cardiology 8% 33-59%Other IM 12% 27-49%General Surgery -3% 25-45%OB-GYN 14% 10-19%Orthopedics 2% 23-54%Anesthesiology 20% 25-48%Psychiatry 9% 16-46%

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Hawaii Population 2006Hawaii Population 2006

1,285,4981,285,498Hawaii StateHawaii State

63,00463,004KauaiKauai

141,320141,320MauiMaui

171,191171,191Island of HawaiiIsland of Hawaii

909,863909,863OahuOahu

U.S. Census Bureau Quick Facts

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Island of Hawaii Population, 2005Island of Hawaii Population, 2005County of Hawaii County of Hawaii DatabookDatabook, 2006, 2006

6,4436,443KauKau

40,72040,720North and South KonaNorth and South Kona

22,28122,281North and South North and South KohalaKohala

90,46390,463Hilo (North and South), Hilo (North and South), HamakuaHamakua, , PunaPuna

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Hawaii HospitalsHawaii HospitalsHawaii County HospitalsHawaii County Hospitals�� Hilo Medical Center (HHSC)*Hilo Medical Center (HHSC)*�� North Hawaii Hospital (private)*North Hawaii Hospital (private)*�� Kona Medical Center (HHSC)*Kona Medical Center (HHSC)*�� KauKau Hospital (HHSC)Hospital (HHSC)�� Hale Hale KoKo��olaola HamakuaHamakua (HHSC)(HHSC)

�� formerly Honokaa Hospitalformerly Honokaa Hospital�� long term care facilitylong term care facility

�� KohalaKohala Hospital (HHSC)Hospital (HHSC)�� Long termLong term�� AcuteAcute

Kauai HospitalsKauai Hospitals�� Wilcox Hospital (HPH)*Wilcox Hospital (HPH)*�� West Kauai Medical Center (HHSC, West Kauai Medical Center (HHSC,

Kauai Veterans Hospital)*Kauai Veterans Hospital)*�� Samuel Samuel MahelonaMahelona Hospital (HHSC)Hospital (HHSC)

−− acute careacute care

Maui County HospitalsMaui County Hospitals�� MauiMaui

�� Maui Memorial Hospital Maui Memorial Hospital (HHSC)*(HHSC)*

�� Kula Hospital (HHSC)Kula Hospital (HHSC)�� Mostly long term careMostly long term care

�� LanaiLanai�� Lanai Community Hospital Lanai Community Hospital

(HHSC)(HHSC)�� Limited acute careLimited acute care�� Long term careLong term care�� No deliveriesNo deliveries

�� MolokaiMolokai�� Molokai Community Hospital Molokai Community Hospital

(Queen�s Healthcare System)*(Queen�s Healthcare System)*

* Provides mother/baby care

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Critical Access Hospitals (CAH)*Critical Access Hospitals (CAH)*�� �To assist small rural hospitals and improve access to health se�To assist small rural hospitals and improve access to health services rvices

in rural communities�, established 1997in rural communities�, established 1997�� More than 35 road miles or, in mountainous terrain or where onlyMore than 35 road miles or, in mountainous terrain or where only

secondary roads exist, more than 15 road miles from another hospsecondary roads exist, more than 15 road miles from another hospitalital�� Provide 24Provide 24--hour emergency care that is necessary for ensuring access to hour emergency care that is necessary for ensuring access to

emergency care services in the area served by the facilityemergency care services in the area served by the facility�� No more than 25 acute care inpatient bedsNo more than 25 acute care inpatient beds�� Provide average inpatient care for a period not exceeding 96 houProvide average inpatient care for a period not exceeding 96 hoursrs

�� CAH in Hawaii:CAH in Hawaii:�� Hale Hale HoolaHoola HamakuaHamakua�� KahukuKahuku Hospital Hospital �� KauKau Hospital Hospital �� Kauai Veterans Memorial Hospital Kauai Veterans Memorial Hospital �� KohalaKohala Hospital Hospital �� Lanai Community Hospital Lanai Community Hospital �� Molokai General Hospital Molokai General Hospital �� Samuel Samuel MahelonaMahelona Memorial HospitalMemorial Hospital

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Health Professional Shortage AreaHealth Professional Shortage Area�� An urban or rural area, which need not conform to geographic An urban or rural area, which need not conform to geographic

boundaries of a political subdivision, and is a rational area foboundaries of a political subdivision, and is a rational area for the r the delivery of health servicesdelivery of health services

�� Primary Care Physician: General or Family Practice, general IntPrimary Care Physician: General or Family Practice, general Internal ernal Medicine, general Pediatrics and Obstetrics/Gynecology with an Medicine, general Pediatrics and Obstetrics/Gynecology with an active practice in the communityactive practice in the community

�� DHHS recommends one primary care physician per 2,000 people in DHHS recommends one primary care physician per 2,000 people in adequately served areas*adequately served areas*

�� Health Professional Shortage Areas defined as one primary care Health Professional Shortage Areas defined as one primary care physician per 3,500 or more people.*physician per 3,500 or more people.*

�� Shortage of specialty care physicians (e.g.Shortage of specialty care physicians (e.g.--cardiology, orthopedic cardiology, orthopedic surgery and others) also greatly affect the population�s health.surgery and others) also greatly affect the population�s health.

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Primary Care PractitionersPrimary Care PractitionersDHHSDHHS

�� All nonAll non--Federal doctors of medicine (M.D.) Federal doctors of medicine (M.D.) and doctors of osteopathy (D.O.) providing and doctors of osteopathy (D.O.) providing direct patient care who practice principally in direct patient care who practice principally in one of the four primary care specialtiesone of the four primary care specialties−− General or Family Practice, General Internal General or Family Practice, General Internal

Medicine, Pediatrics, and Obstetrics and Medicine, Pediatrics, and Obstetrics and Gynecology Gynecology

�� Physicians engaged solely in administration, Physicians engaged solely in administration, research, and teaching are excluded for research, and teaching are excluded for counting purposescounting purposes

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Primary Care ProvidersPrimary Care ProvidersHealth Professional Shortage AreasHealth Professional Shortage Areas

�� Department of Health and Human Services Department of Health and Human Services (DHHS)(DHHS)

�� Recommends one primary care physician (PCP) Recommends one primary care physician (PCP) per 2000 people in adequately served areasper 2000 people in adequately served areas

�� Health Professional Shortage Areas (HPSA) Health Professional Shortage Areas (HPSA) defined as one primary care physician per 3500 defined as one primary care physician per 3500 people or morepeople or more

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Determination of Unusually High Needs for Determination of Unusually High Needs for Primary Medical Care Services Primary Medical Care Services -- DHHSDHHS

An area will be considered as having Unusually An area will be considered as having Unusually High Needs for Primary Health Care Services if High Needs for Primary Health Care Services if at least one of the following criteria is met:at least one of the following criteria is met:(a) The area has more than 100 births per year per (a) The area has more than 100 births per year per

1,000 women aged 15 1,000 women aged 15 -- 4444(b) More than 20 infant deaths per 1,000 live births(b) More than 20 infant deaths per 1,000 live births(c) More than 20% of the population (or of all (c) More than 20% of the population (or of all

households) have incomes below the poverty levelhouseholds) have incomes below the poverty level

Page 27: Kamemoto lori,  sood sneha

Health Professional Shortage AreasHealth Professional Shortage Areas

Hawaii Health Information Corporation Website

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Determination of Insufficient Capacity of Determination of Insufficient Capacity of Existing Primary Care Providers Existing Primary Care Providers -- DHHSDHHS

An area's existing primary care providers will be considered An area's existing primary care providers will be considered to have Insufficient Capacity if at least two of the following to have Insufficient Capacity if at least two of the following criteria are met:criteria are met:(a) More than 8,000 office or outpatient visits per year per FTE(a) More than 8,000 office or outpatient visits per year per FTE PCPPCP(b) Unusually long waits for appointments for routine medical se(b) Unusually long waits for appointments for routine medical services rvices

(i.e., more than 7 days for established patients and 14 days for(i.e., more than 7 days for established patients and 14 days for new new patients)patients)

(c) Excessive average waiting time at primary care providers (lo(c) Excessive average waiting time at primary care providers (longer nger than one hour where patients have appointments or two hours wherthan one hour where patients have appointments or two hours where e patients are treated on a firstpatients are treated on a first--come, firstcome, first--served basis)served basis)

(d) Evidence of excessive use of emergency room facilities for r(d) Evidence of excessive use of emergency room facilities for routine outine primary careprimary care

(e) A substantial proportion (2/3 or more) of the area's physici(e) A substantial proportion (2/3 or more) of the area's physicians do ans do not accept new patientsnot accept new patients

(f) Abnormally low utilization of health services, as indicated (f) Abnormally low utilization of health services, as indicated by an by an average of 2.0 or less office visits per year on the part of theaverage of 2.0 or less office visits per year on the part of the area's area's populationpopulation

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Challenges faced by Challenges faced by Rural PhysiciansRural Physicians

�� Longer Work HoursLonger Work Hours−− More patientsMore patients−− More complicated patient careMore complicated patient care−− Harder to refer patients for specialist careHarder to refer patients for specialist care--lack of specialty lack of specialty

carecare−− Physicians not only face an increased outpatient load, but are Physicians not only face an increased outpatient load, but are

also responsible for providing increased inalso responsible for providing increased in--hospital services hospital services during the day, night and weekendsduring the day, night and weekends

�� More patient visitsMore patient visits−− Example: Hilo Ob sees about 60Example: Hilo Ob sees about 60--100 patients per day in the 100 patients per day in the

office; busy Honolulu Ob sees up to 40 patients per dayoffice; busy Honolulu Ob sees up to 40 patients per day�� Less favorable insurance distributionLess favorable insurance distribution

−− More Medicaid/QUEST patientsMore Medicaid/QUEST patients−− More patients with no insuranceMore patients with no insurance

�� Resulting in lower income per patient Resulting in lower income per patient

Page 30: Kamemoto lori,  sood sneha

American Medical Association. Socioeconomic Characteristics of Medical Practice 1996. Chicago, IL: American Medical Association, 1996.

Physician Hours Worked Per WeekPhysician Hours Worked Per Week

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Total Number of Patients Per WeekTotal Number of Patients Per Week

American Medical Association. Socioeconomic Characteristics of Medical Practice 1996. Chicago, IL: American Medical Association, 1996.

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Percentage of Physician Revenue Percentage of Physician Revenue from Medicare and Medicaidfrom Medicare and Medicaid

Frenzen Paul D. The Medicare and Medicaid Programs in Rural America. U.S. Department of Agriculture, March 1996.

Page 33: Kamemoto lori,  sood sneha

Physician Average Gross Practice Physician Average Gross Practice Revenues/IncomeRevenues/Income

American Medical Association. Socioeconomic Characteristics of Medical Practice 1996. Chicago, IL: American Medical Association, 1996.

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Health Disparities on the Neighbor IslandsHealth Disparities on the Neighbor Islands

�� Lack of health care providersLack of health care providers�� Physician ShortagePhysician Shortage�� Lack of Subspecialists and Subspecialty ClinicsLack of Subspecialists and Subspecialty Clinics�� Nursing shortageNursing shortage

�� SocioeconomicSocioeconomic�� IncomeIncome�� Drug useDrug use�� Health insuranceHealth insurance

�� GeographyGeography�� Sparse populationSparse population�� Lack of transportationLack of transportation

�� Race/Ethnic: cultural factorsRace/Ethnic: cultural factors

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Hawaii Population by Ethnicity (%) Hawaii Population by Ethnicity (%) 20062006

0%

20%

40%

60%

80%

100%

State HawaiiCounty

Two or more

Hispanic or Latino

Asian

Hawaiian/Pacific Isl

Am Indian/AlaskaNatCaucasian

Af AmericanState

U.S. Census Bureau Quick Facts 2006

State Haw a ii CoAf Am eric 2.5 0.7Caucasian 28.6 37Am Indian 0.5 0.7Haw aiian/ 9.1 10.8Asian 40 24.3Hispanic o 7.8 10.8Tw o or mo 19.4 26.5

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Median Household Income, 2004Median Household Income, 2004

$44,334$44,334U.S.A.U.S.A.

$45,146$45,146KauaiKauai

$49,065$49,065MauiMaui

$42,043$42,043Island of HawaiiIsland of Hawaii

$54,714$54,714OahuOahu

$51,359$51,359Hawaii StateHawaii State

U.S. Census Bureau Quick Facts

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Persons Below Poverty Level, 2004Persons Below Poverty Level, 200412.7%12.7%U.S.A.U.S.A.

8.6%8.6%KauaiKauai

8.3%8.3%MauiMaui

10.8%10.8%Island of HawaiiIsland of Hawaii

8.8%8.8%OahuOahu

9.0%9.0%Hawaii StateHawaii State

U.S. Census Bureau Quick Facts

Page 38: Kamemoto lori,  sood sneha

Hawaii Insurance Hawaii Insurance PayorPayor MixMix

Hawaii Health Information Corporation, Non-federal hospitals only

Page 39: Kamemoto lori,  sood sneha

Hawaii Health Information Corporation, Inpatient Database, Non-federal hospitals only.

Hawaii�s Uninsured Population, 2003-2005

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Hawaii PhysiciansHawaii Physicians�� Physicians per population: State of Hawaii ranks Physicians per population: State of Hawaii ranks

77thth in the U.S. with 3,770 physicians (2007 AAMC in the U.S. with 3,770 physicians (2007 AAMC Physician Workforce Physician Workforce DatabookDatabook) ) −− 293.3 active physicians per 100,000 population293.3 active physicians per 100,000 population

�� 47% of Hawaii MDs are over 50 years old (AMA)47% of Hawaii MDs are over 50 years old (AMA)−− Hawaii ranks 7Hawaii ranks 7thth for number of physicians over 60 years for number of physicians over 60 years

of age (25% > 60 years) (2007 State Workforce of age (25% > 60 years) (2007 State Workforce Handbook)Handbook)

−− Who will replace them as they retire?Who will replace them as they retire?

�� Patients still unable to find primary care providers Patients still unable to find primary care providers and certain areas of specialty care, particularly on and certain areas of specialty care, particularly on the neighbor islandsthe neighbor islands

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Inadequate Distribution Inadequate Distribution of Hawaii Physiciansof Hawaii Physicians

�� May be adequate number of health care providers May be adequate number of health care providers in Hawaii, however, disproportionate distribution of in Hawaii, however, disproportionate distribution of providers resulting in inadequate supply in rural providers resulting in inadequate supply in rural areasareas

�� ~ ~ 79% of Hawaii physicians on Oahu 79% of Hawaii physicians on Oahu �� 4% Kauai4% Kauai�� 8% Maui8% Maui�� 9% Island of Hawaii9% Island of Hawaii

�� Growing neighbor island population, but physician Growing neighbor island population, but physician numbers not increasingnumbers not increasingInada,Withy,Andaya,HixonInada,Withy,Andaya,Hixon, 2005, 2005

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Lack of Access to Health Care:Lack of Access to Health Care:Geographical LocationGeographical Location

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Ob/Gyn Residency Program Ob/Gyn Residency Program Applications DecliningApplications Declining

PGY 1 2002 2003 2004 Number of Positions offered 1130 1151 1142 Number of US Seniors Applying 920 828 743 Number of total Applicants 1389 1367 1118 Positions Per US Senior 1.2 1.4 1.5 Positions Per Total Applicants 0.8 0.8 1.02 Number of Positions Filled by US Seniors (%) 850 (75.2) 786 (68.3) 743 (65.1) Number of Positions Filled, Total Applicants (%) 1067 (94.4) 1050 (91.2) 1066 (95.3) Number of Unfilled Positions (%) 63 (5.5) 101 (8.8) 76 (6.7)

National Residency Matching Program data

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Obstetrics and Gynecology PracticeObstetrics and Gynecology Practice

�� In a typical week there are approximately 85 In a typical week there are approximately 85 patient contacts (80% seen in the office and patient contacts (80% seen in the office and 20% in the hospital/surgery), ACOG20% in the hospital/surgery), ACOG

�� Women of a wide age range, nearly 80% are Women of a wide age range, nearly 80% are 1515��45 years old45 years old−− ~~ 70% of patients cared for by an obstetrician70% of patients cared for by an obstetrician��

gynecologist receive most or all of their medical care gynecologist receive most or all of their medical care from that physician onlyfrom that physician only

�� Malpractice for obstetrics practice up to Malpractice for obstetrics practice up to $100,000+ per year depending on location$100,000+ per year depending on location−− Hawaii: $40,000Hawaii: $40,000--80,000 per year80,000 per year

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Prematurity, Prenatal Care, and Teen birth Prematurity, Prenatal Care, and Teen birth Rates in HawaiiRates in Hawaii

3.3%3.3%2.0%***2.0%***2.21%**2.21%**Teen birth Teen birth rate***rate***

5.8%5.8%3.7%3.7%3.6%3.6%Late/no PNC*Late/no PNC*

13.3%13.3%12.8%12.8%12.2%12.2%Prematurity*Prematurity*

Island of Island of HawaiiHawaii

Hawaii Hawaii StateState

NationalNational

*2001-2003: Peristats, March of Dimes** Births for teens age 17 and under in 1999-2004 (derived from State of Hawaii Primary Needs Assessment Data Book 2005, Faily Health Services Division, Hawaii Dept. of Health***Birth data for 15-17 year olds 2004 (derived from National Vital Statistics Report Website)

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Deliveries per Year: OahuDeliveries per Year: Oahu

�� Queens Medical CenterQueens Medical Center�� approximately 2200 deliveries per yearapproximately 2200 deliveries per year

�� Kapi�olaniKapi�olani Medical CenterMedical Center�� approximately 5000approximately 5000--6000 deliveries per year6000 deliveries per year

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Deliveries per Year: Maui and Deliveries per Year: Maui and Kauai, 2007Kauai, 2007

�� Maui Memorial Hospital: 1899Maui Memorial Hospital: 1899�� Wilcox Hospital: 556Wilcox Hospital: 556�� West Kauai Medical Center (Barking Sands): West Kauai Medical Center (Barking Sands):

240 240 �� Molokai: 38 (NurseMolokai: 38 (Nurse--Midwives)Midwives)�� Lanai: Mothers asked to leave island 2 weeks Lanai: Mothers asked to leave island 2 weeks

prior to deliveryprior to delivery--referred to Oahu or Maui; no referred to Oahu or Maui; no anesthesia on island; occasional unanticipated anesthesia on island; occasional unanticipated deliveries prenatal care by two GPsdeliveries prenatal care by two GPs

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Deliveries per Year: Island of Deliveries per Year: Island of Hawaii, 2007Hawaii, 2007

544544Kona HospitalKona Hospital

626626North Hawaii North Hawaii Community Community

HospitalHospital

11781178Hilo Medical Hilo Medical CenterCenter

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Hawaii: Number of ObstetriciansHawaii: Number of Obstetricians

�� Oahu: 161***Oahu: 161***�� Island of Hawaii: 11*Island of Hawaii: 11*

Hilo: 4.5Hilo: 4.5North Hawaii: 2**North Hawaii: 2**Kona: 4.5Kona: 4.5

�� Maui: 12Maui: 12�� Kauai: 6.5**Kauai: 6.5**

*Does not include midwives**1.0 FTE locum tenems coverage

**Midwives: 5, 3 do hospital work***Hawaii ACOG

Oahu

BigIslandMaui

Kauai

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Hawaii: Patient Population to Hawaii: Patient Population to Ob/Gyn Ratio*Ob/Gyn Ratio*

�� Oahu: 2,119 : 1Oahu: 2,119 : 1�� Island of Hawaii: 5,350 : 1Island of Hawaii: 5,350 : 1−− Hilo 7,538 : 1Hilo 7,538 : 1−− North Hawaii 4,178 : 1North Hawaii 4,178 : 1−− Kona 3,393 : 1Kona 3,393 : 1

�� Maui: 4,416 : 1Maui: 4,416 : 1�� Kauai: 3,364 : 1Kauai: 3,364 : 1

*estimated women ≥ 18 y.o., however, Ob/Gyns also care for adolescent females

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Pediatric Population, 2006Pediatric Population, 2006< 18 yrs: 24.6%< 18 yrs: 24.6%< 5 yrs: 6.8%< 5 yrs: 6.8%

U.S.A.U.S.A.

< 18 yrs: 23.7% < 18 yrs: 23.7% < 5 yrs: 6.4%< 5 yrs: 6.4%

KauaiKauai

< 18 yrs: 23.6%< 18 yrs: 23.6%< 5 yrs: 6.6%< 5 yrs: 6.6%

MauiMaui

< 18 yrs: 23.4%< 18 yrs: 23.4%< 5 yrs: 6.3%< 5 yrs: 6.3%

Island of HawaiiIsland of Hawaii

< 18 yrs: 23.1%< 18 yrs: 23.1%< 5 yrs: 6.9%< 5 yrs: 6.9%

OahuOahu

< 18 yrs: 23.2%< 18 yrs: 23.2%< 5 yrs: 6.8%< 5 yrs: 6.8%

Hawaii StateHawaii State

U.S. Census Bureau Quick Facts

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Factors Affecting Neighbor Island Factors Affecting Neighbor Island Health Disparities in PediatricsHealth Disparities in Pediatrics

�� Shortage of Pediatricians on neighbor islandsShortage of Pediatricians on neighbor islands�� No level II or level III nurseries, resulting in need No level II or level III nurseries, resulting in need

to transport sick babies to Oahuto transport sick babies to Oahu�� No Pediatric ICU services leading to large No Pediatric ICU services leading to large

number of Pediatric transports to Oahunumber of Pediatric transports to Oahu�� Inadequate numbers of PediatricInadequate numbers of Pediatric--trained nurses; trained nurses;

lack of adequate bed spaces for Pediatric lack of adequate bed spaces for Pediatric patientspatients

�� Emergency room used as �outpatient clinic�Emergency room used as �outpatient clinic�

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U.S. Patient to Pediatrician Ratios*U.S. Patient to Pediatrician Ratios*

�� Urban areasUrban areas−− 1546 Patients: Pediatrician1546 Patients: Pediatrician

�� Less populated areasLess populated areas−− 1915 Patients: Pediatrician1915 Patients: Pediatrician

�� Solo PracticeSolo Practice−− 2097 Patients: Pediatrician2097 Patients: Pediatrician

*Visits by patients may be nearly double number of Patients: PediatricianPediatric Research in Office Settings, American Academy of PediaPediatric Research in Office Settings, American Academy of Pediatrics, 1999trics, 1999

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Hawaii: Number of PediatriciansHawaii: Number of Pediatricians

�� Oahu: 233Oahu: 233--263263�� Island of Hawaii: 23Island of Hawaii: 23�� Maui: 20Maui: 20�� Kauai: 8Kauai: 8

OahuHawaiiMauiKauai

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Hawaii: Patients to Pediatrician Hawaii: Patients to Pediatrician Ratios, 2008Ratios, 2008

�� Oahu: 907:PediatricianOahu: 907:Pediatrician�� Hawaii Island:Hawaii Island:

�� 1741:Pediatrician (hospitalists included)1741:Pediatrician (hospitalists included)�� 2002:Pediatrician (outpatient)2002:Pediatrician (outpatient)

�� Maui: 1762 Maui: 1762 patients:Pediatricianpatients:Pediatrician�� Kauai: 1866 Kauai: 1866 patients:Pediatricianpatients:Pediatrician

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Patients : PediatricianPatients : PediatricianIsland of Hawaii*Island of Hawaii*

�� Hilo area: Hilo area: �� Outpatient: 2352:1 (9 Outpatient: 2352:1 (9

Pediatricians)Pediatricians)�� Inpatient: 3528:1 (6 Inpatient: 3528:1 (6

Pediatricians**) Pediatricians**) �� North Hawaii: 1114:1North Hawaii: 1114:1�� Kona: 1696:1Kona: 1696:1

*Only includes physicians working ≥ 50%** Three community physicians still doing hospital work; three hospitalist Pediatricians, two hired by HMC, including one locums tenens physician; long-term plan for HMC hospitalists to also provide outpatient care

�� HiloHilo−− Pediatricians: 12Pediatricians: 12

�� North HawaiiNorth Hawaii−− Pediatricians: 5Pediatricians: 5

�� KonaKona−− Pediatricians: 6Pediatricians: 6

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Hawaii: Age of PediatriciansHawaii: Age of Pediatricians�� Island of HawaiiIsland of Hawaii

�� 26% (6/23) over age 5526% (6/23) over age 55�� 50% (10/20) over age 5050% (10/20) over age 50

�� MauiMaui�� 50% (10/20) over age 5050% (10/20) over age 50�� 25% (8/20) over age 5525% (8/20) over age 55

�� Kauai: 8Kauai: 8�� 50% (4/8) over age 5550% (4/8) over age 55

�� Recruitment of new Pediatricians difficultRecruitment of new Pediatricians difficult

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Hawaii Island Insurer Distribution, 2003Hawaii Island Insurer Distribution, 2003

Data analysis of Big Island Newborns at Data analysis of Big Island Newborns at KapiolaniKapiolani Medical Center: 50% QuestMedical Center: 50% Quest

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Neonatal and Pediatric Transports Neonatal and Pediatric Transports from the Island of Hawaii 2007from the Island of Hawaii 2007

KapiolaniKapiolani Medical Center Transport Team dataMedical Center Transport Team data

52%52%10210260%60%7373BI TotalBI Total

1%1%171718%18%2222KonaKona

10%10%202010%10%1212N. HawaiiN. Hawaii

33%33%656533%33%3939HiloHilo

% NI % NI TransportsTransports

PediatricPediatric% NI % NI TransportsTransports

NeonatalNeonatalLocationLocation

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Neonatal and Pediatric Transports Neonatal and Pediatric Transports from Other Neighbor Islands 2007from Other Neighbor Islands 2007

KapiolaniKapiolani Medical Center Transport Team dataMedical Center Transport Team data

3.5%3.5%771.7%1.7%22MolokaiMolokai

0%0%000.8%0.8%11LanaiLanai

25%25%484826%26%3131MauiMaui

19%19%383811%11%1313KauaiKauai

% NI % NI TransportsTransports

PediatricPediatric% NI % NI TransportsTransports

NeonatalNeonatalLocationLocation

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Hawaiian Monk Seal

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Projected U.S. Physician ShortageProjected U.S. Physician Shortage

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Physician/Provider Shortages MatterPhysician/Provider Shortages Matter

�� Diminished capacity for disease prevention, Diminished capacity for disease prevention, screening, early diagnosis & treatmentscreening, early diagnosis & treatment

�� Higher emergency room utilizationHigher emergency room utilization�� Higher hospitalization rateHigher hospitalization rate�� More intense treatmentMore intense treatment�� Higher cost to the Higher cost to the systemsystem�� Less healthy populationLess healthy population

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Physician Shortage problem has Physician Shortage problem has Several ComponentsSeveral Components

�� Absolute number of physiciansAbsolute number of physicians�� MalMal--distribution of physicians, in distribution of physicians, in

particular the neighbor islands particular the neighbor islands shortageshortage

�� Physician specialty mixPhysician specialty mix−− Example: HawaiiExample: Hawaii��s loss of orthopedic s loss of orthopedic

surgeons across the whole state surgeons across the whole state including Oahuincluding Oahu

�� Services providedServices provided

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Supply FactorsSupply Factors�� Aging of the workforce (1/3 > 55 in U.S., 47% > Aging of the workforce (1/3 > 55 in U.S., 47% >

50 in Hawaii)50 in Hawaii)−− Earlier retirementEarlier retirement−− Mass Mass ��BoomerBoomer�� retirementretirement

�� Productivity influencesProductivity influences−− GenerationalGenerational−− Gender relatedGender related−− Age relatedAge related−− Insurance reimbursement issuesInsurance reimbursement issues

�� Liability issues contribute to shortageLiability issues contribute to shortage�� AAMC proposes to increase U.S. medical school AAMC proposes to increase U.S. medical school

enrollment by 30% by 2015enrollment by 30% by 2015−− Takes up to14 years of education to produce a Takes up to14 years of education to produce a

practicing physicianpracticing physician�� NonNon--physician clinicians: Physician Assistants, physician clinicians: Physician Assistants,

Nurse Practitioners, Nurse Midwives, etcNurse Practitioners, Nurse Midwives, etc

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Demand FactorsDemand Factors

�� Growing population Growing population −−U.S. population expected to grow by 12% by U.S. population expected to grow by 12% by

20202020−−Hawaii: Big Island expected to grow by 35% by Hawaii: Big Island expected to grow by 35% by

20202020�� Aging of the populationAging of the population

−−More patient visits and chronic diseaseMore patient visits and chronic disease�� Rising expectations of patientsRising expectations of patients�� Increasing wealthIncreasing wealth�� Increasing incidence of lifestyleIncreasing incidence of lifestyle--related related

chronic diseaseschronic diseases

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Physician RecruitmentPhysician RecruitmentLimiting FactorsLimiting Factors

�� Need for a sufficient caseload (i.e.Need for a sufficient caseload (i.e.--population size) to provide a financial basepopulation size) to provide a financial base

�� Professional satisfactionProfessional satisfaction−− interesting cases/proceduresinteresting cases/procedures−− peer contact and interactionpeer contact and interaction

�� Reasonable lifestyleReasonable lifestyle−− reasonable frequency of call reasonable frequency of call −− adequate vacation/offadequate vacation/off--time coveragetime coverage

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Barriers to Physician RecruitmentBarriers to Physician Recruitment�� Burden on generalists to practice without specialists Burden on generalists to practice without specialists �� Generalists work harder for the same reimbursementGeneralists work harder for the same reimbursement�� New physicians are not prepared for rural practiceNew physicians are not prepared for rural practice�� Geography and traffic are barriers to multiple officesGeography and traffic are barriers to multiple offices�� Call burden is overwhelmingCall burden is overwhelming�� Lack of financial security (income vs. cost of living)Lack of financial security (income vs. cost of living)�� Family responsibilities (spousal employment and Family responsibilities (spousal employment and

education choices)education choices)�� Limited professional community/peer interactionLimited professional community/peer interaction�� Older healthcare facilities/hospitalsOlder healthcare facilities/hospitals�� Patient transfer is difficultPatient transfer is difficult

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Possible SolutionsPossible SolutionsMultipronged ApproachMultipronged Approach

�� No one simple �solution� will �work�, must use No one simple �solution� will �work�, must use multipronged approach to this complex problemmultipronged approach to this complex problem

�� No statewide planNo statewide plan−− All stakeholders should assess the needs and discuss All stakeholders should assess the needs and discuss

a statewide plan, assessment/outcomesa statewide plan, assessment/outcomes−− Must include clinicians, those who take care of Must include clinicians, those who take care of

patients with real world experiencepatients with real world experience−− Physicians particularly from neighbor islands and Physicians particularly from neighbor islands and

those specialties particularly affected by the shortagethose specialties particularly affected by the shortage−− LawmakersLawmakers−− Relevant physician, public health, community, Relevant physician, public health, community,

physician extenders, medical school, residency physician extenders, medical school, residency program and othersprogram and others

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How Health Insurance Reimbursements HurtHow Health Insurance Reimbursements HurtPhysician Recruitment/Retention and Primary CarePhysician Recruitment/Retention and Primary Care

�� For the same service (e.g.For the same service (e.g.-- hysterectomy) physicians hysterectomy) physicians receive varied fees across the country, as well as differing receive varied fees across the country, as well as differing amounts within the same state by the same insurance amounts within the same state by the same insurance company for the same procedurecompany for the same procedure

�� Hawaii reimbursement rates said to be at least oneHawaii reimbursement rates said to be at least one--fourth fourth to oneto one--third lower than California ratesthird lower than California rates−− If physician can earn significantly more for the same work If physician can earn significantly more for the same work

elsewhere, this makes recruitment very difficultelsewhere, this makes recruitment very difficult−− Frustrates physicians who practice here, and they leave HawaiiFrustrates physicians who practice here, and they leave Hawaii

�� Example: cited by orthopedic surgeons as one of the main reasonExample: cited by orthopedic surgeons as one of the main reasons s for leaving Hawaiifor leaving Hawaii

�� Reimbursement issues may also affect choice of specialty, Reimbursement issues may also affect choice of specialty, and may be one of the reasons medical students are not and may be one of the reasons medical students are not choosing primary carechoosing primary care−− In most countries, 70In most countries, 70--80% of all doctors are primary care 80% of all doctors are primary care

physicians, but in the U.S., it is almost the oppositephysicians, but in the U.S., it is almost the opposite

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American College of Obstetricians and GynecologistsAmerican College of Obstetricians and GynecologistsNational Survey, 2006National Survey, 2006

�� Increasing malpractice insurance premiums and fear of Increasing malpractice insurance premiums and fear of lawsuits continue to change how medicine is practicedlawsuits continue to change how medicine is practiced−− 70% of Ob70% of Ob--GynsGyns changed how they practice due to the lack of changed how they practice due to the lack of

available or affordable insuranceavailable or affordable insurance−− 65% made changes due to the fear of liability claims65% made changes due to the fear of liability claims

�� 77--8% have stopped practicing obstetrics because of 8% have stopped practicing obstetrics because of insurance affordability or fear of litigationinsurance affordability or fear of litigation−− Average age stopped obstetrics: 48 Average age stopped obstetrics: 48 y.oy.o

�� 89% have had at least one liability claim filed against 89% have had at least one liability claim filed against themthem−− Average of 2.6 malpractice suits Average of 2.6 malpractice suits −− In the last three years, 55% were sued at least onceIn the last three years, 55% were sued at least once−− 70% of claims were either dropped by the plaintiff, dismissed or70% of claims were either dropped by the plaintiff, dismissed or

settled without paymentsettled without payment

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Malpractice Insurance Reform Malpractice Insurance Reform oror�Why Doctors are Heading for Texas��Why Doctors are Heading for Texas�

Over the past three years, some 7,000 Over the past three years, some 7,000 M.D.sM.D.s have flooded into Texas, many have flooded into Texas, many from Tennessee... Why? Two words: Tort reform.from Tennessee... Why? Two words: Tort reform.

In 2003 and in 2005, Texas enacted a series of reforms to the stIn 2003 and in 2005, Texas enacted a series of reforms to the state's civil ate's civil justice system. They are stunning in their success. Texas Medicajustice system. They are stunning in their success. Texas Medical Liability l Liability Trust, one of the largest malpractice insurance companies in theTrust, one of the largest malpractice insurance companies in the state, has state, has slashed its premiums by 35%, saving doctors some $217 million ovslashed its premiums by 35%, saving doctors some $217 million over four er four years. There is also a competitive malpractice insurance industryears. There is also a competitive malpractice insurance industry in Texas, y in Texas, with over 30 companies competing for business. This is driving rwith over 30 companies competing for business. This is driving rates down.ates down.

The result is an influx of doctors so great that recently the StThe result is an influx of doctors so great that recently the State Board of ate Board of Medical Examiners couldn't process all the new medicalMedical Examiners couldn't process all the new medical--license applications license applications quickly enough. The board faced a backlog of 3,000 applications.quickly enough. The board faced a backlog of 3,000 applications. To handle To handle the extra workload, the legislature rushed through an emergency the extra workload, the legislature rushed through an emergency appropriation last year.appropriation last year.

Now many of the newly arriving doctors are heading to rural or uNow many of the newly arriving doctors are heading to rural or underserved nderserved parts of the state. Four new anesthesiologists have headed to Beparts of the state. Four new anesthesiologists have headed to Beaumont, aumont, for example. Meanwhile, San Antonio has experienced a 52% growthfor example. Meanwhile, San Antonio has experienced a 52% growth in the in the number of new doctors.number of new doctors.

Wall Street Journal, May 17, 2008

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Hawaii Medical Students and ResidentsHawaii Medical Students and ResidentsState RankingsState Rankings

�� Hawaii ranks 5Hawaii ranks 5thth in % who graduated from a in % who graduated from a medical or osteopathic school in that state and medical or osteopathic school in that state and are active MDs in that state (52.8%, State are active MDs in that state (52.8%, State median: 39.7%)median: 39.7%)

�� Hawaii ranks 41Hawaii ranks 41stst in % who completed residency in % who completed residency in that state and are active MDs in the same in that state and are active MDs in the same state (37.5%, State median: 45%)state (37.5%, State median: 45%)

�� Hawaii ranks 1Hawaii ranks 1stst in % who completed both in % who completed both medical school and residency in that state and medical school and residency in that state and are active MDs in the same state (83.5%, State are active MDs in the same state (83.5%, State median: 67.3%)median: 67.3%)

2007 State Physician Workforce Databook, AAMC

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Influence of Student Loan Debt on Influence of Student Loan Debt on Career ChoiceCareer Choice

Salter and Kimball, J Am Acad Dermatol. 2006

Incentive to practice in underserved areas: Debt payment?Medical school tuition �payback� via years of service?

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Effect of Birth Origin County on Rural Effect of Birth Origin County on Rural Practice, 2006Practice, 2006

Figure. Impact of birth origin county on rural practice of the 2006 physician workforce.

Am Family Physician, July 2007

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Rural Residency rotations/tracks Rural Residency rotations/tracks and Career Choicesand Career Choices

�� Texas Rural Family Medicine Track (Nash, Tex Med Texas Rural Family Medicine Track (Nash, Tex Med 2008)2008)−− As of 2007, 6 out of 7 residents who completed the program are As of 2007, 6 out of 7 residents who completed the program are

practicing in rural areaspracticing in rural areas�� Graduates of northern Ontario family medicine residency Graduates of northern Ontario family medicine residency

programs practice where they train (programs practice where they train (HengHeng, , Can J Rural Can J Rural MedMed 2007)2007)−− Rural residency program graduates were 4.56 times more likely Rural residency program graduates were 4.56 times more likely

to practice in a rural areato practice in a rural area�� New Mexico mailed 1,396 surveys (59% response rate) New Mexico mailed 1,396 surveys (59% response rate)

to health professional graduatesto health professional graduates−− Size of childhood town, rural practicum completion, discipline, Size of childhood town, rural practicum completion, discipline,

and age at graduation were significantly associated with rural and age at graduation were significantly associated with rural practice choice practice choice

Establish Hawaii Residency Program rotations on neighbor islands?

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Other IssuesOther Issues

�� Tax incentives or other incentives for underserved/rural Tax incentives or other incentives for underserved/rural physician practicephysician practice

�� Establish telemedicine lines/usage to easily consult Establish telemedicine lines/usage to easily consult specialists on Oahu from their officesspecialists on Oahu from their offices−− Insurance reimbursement for telemedicineInsurance reimbursement for telemedicine

�� Hospitals in underserved areas need to change/improve Hospitals in underserved areas need to change/improve to keep physicians or they will leave the areato keep physicians or they will leave the area−− Closely involve physicians in improvements Closely involve physicians in improvements

�� �New� paradigm �New� paradigm −− Use of physician extenders/nonUse of physician extenders/non--physician clinicians physician clinicians −− Graduates of Physician Assistant and Nurse Practitioner Graduates of Physician Assistant and Nurse Practitioner

programs have been increasing over the past ten yearsprograms have been increasing over the past ten years−− Team approach: the Medical HomeTeam approach: the Medical Home

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