the vermont primary care workforce

The Vermont Primary Care Workforce2012 SNAPSHOT

wOrkfOrce SHOwS imPrOvemeNT buT SHOrTAge iN AdulT PrimArY cAre PerSiSTS

About vermont AHec

The Vermont Area Health Education Centers (AHEC) Program, in collaboration with many partners, improves access to quality health care through its focus on workforce development. AHEC work includes: support for pipeline programs in health careers awareness and exploration for Vermont youth; support for and engagement of health professions students at the University of Vermont and residents at Fletcher Allen Health Care; and support to help recruit and retain a high-quality healthcare workforce in Vermont.

In addition to health workforce development, AHEC brings educational and quality improvement programming to Vermont’s primary care practitioners and supports community health education.

AHEC believes that success in healthcare innovation, transformation, and reform depends on an adequate supply and distribution of well-trained healthcare professionals so that all Vermonters, including those who live in rural areas and underserved populations, have access to high-quality care.

AHec History & Partners

The Vermont Area Health Education Centers Program was established in 1996 by the Office of Primary Care at the University of Vermont College of Medicine. AHEC is funded through multiple grants and contracts including: Federal HRSA Title VII, State of Vermont, Vermont Department of Health, University of Vermont College of Medicine, Fletcher Allen Health Care, Vermont’s 13 community hospitals, private foundations, and individual contributors.

The statewide infrastructure of AHEC consists of a program office at the University of Vermont College of Medicine and three regional centers which are each a 501(c)(3), non-profit organization. AHEC is a dynamic, academic-community partnership linking the University of Vermont College of Medicine and communities in every county of the state.

Acknowledgments

We thank all those involved in primary care in Vermont who helped produce this report, including: the Vermont primary care practices who provided practice- and practitioner-level information; Helen Riehle, Judy Wechsler, and Tammy Johnson of Champlain Valley AHEC; Marty Hammond, Susan White, and Doreen Moran of Southern Vermont AHEC; Nicole LaPointe and Mary E. Fleck of Northeastern Vermont AHEC; the UVM AHEC staff; and Laurie Hurowitz, PhD, Health Workforce Researcher.

TAble Of cONTeNTS

Primary Care Workforce Summary 2012 .................................... 1

Background, Benchmarks, Challenges, Ongoing Work ............. 2

Primary Care Practitioners – Statewide Findings 2012

Primary Care Practice Sites ................................................... 4

From Individual Practitioners to FTEs .................................. 4

Primary Care Practitioners (in FTEs)

By Specialty .................................................................... 5

Limiting New Patients by Specialty .............................. 6

By Region ....................................................................... 7

Limiting New Patients by Region ................................. 9

2012 Survey Findings by AHEC Region

Northeastern Vermont ....................................................... 10

Champlain Valley ................................................................ 11

Southern Vermont .............................................................. 12

Endnotes ..................................................................................... 13

contact AHec

university of vermont college of medicine Office of Primary care AHec Program

Burlington, VT 802-656-2179www.vtahec.org

Northeastern vermont Area Health education center

St. Johnsbury, VT 802-748-2506www.nevahec.org

champlain valley Area Health education center

St. Albans, VT802-527-1474www.cvahec.org

Southern vermont Area Health education center

Springfield, VT 802-885-2126www.svahec.org

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•

Windham

WindsorRutland

Bennington

Washington

Orange

Caledonia

LamoilleOrleans

Essex

•

Franklin

Chittenden

Addison

•

Grand Isle

•

WorkforceShowsImprovementbutShortageinAdultPrimaryCarePersists

PrimArY cAre wOrkfOrce SummArY 2012

• InVermont,duringthethreeyearperiod2010to2012thenumberofprimary

carepractitionersgrew;however, the shortage of adult primary care

practitioners has persisted across all regions of the state.Primarycare

practitionersincludephysicians,advancedpracticeregisterednurses,certified

nursemidwives,andcertifiedphysicianassistantswhoworkatprimarycare

practicesitesinVermont.

• Despitesomeincreasesinfamilymedicine,pediatrics,

andobstetrics-gynecologypractitionersovertime,

theshortfallininternalmedicinepersisted.

Three-yeartrenddatashowedacontinued

declineinthenumberofinternalmedicine

physiciansfrom2010to2012.

• Theneedforprimarycarepractitionerswhocare

foradultswasfurthersupportedbythepercent

ofpractitionerslimitingorclosingtheirpracticeto

newpatientsin2012.Whiletheoverallincrease

intotalpractitionerswasassociatedwithasmall

declineinthepercentlimitingorclosingtheir

practice,two-thirds of the internal medicine

and almost half of the family medicine

physicians limited or closed their practice

to new patients in 2012.

• PrimaryCarePracticeSitesinVermontAHECRegions

2 www.vtahec.org

background: Annual AHec Survey

Inthisreportweexaminetheclinicalhoursofprimarycarepractitioners(PCPs)includingphysicians(MD/DOs),advancedpractiticeregisterednurses(APRNs),certifiednursemidwives(CNMs),andcertifiedphysicianassistants(PA-Cs)inprimarycarepractices.AnalysesarepresentedbyprimarycarespecialtytoidentifytheneedsofdifferentpopulationsofVermonters:

• familymedicinepractitionersservechildrenthroughadults;

• generalinternalmedicinepractitionersserveadolescentsandadults;

• generalpediatricpractitionersservechildrenandadolescents;and

• generalobstetrics-gynecologypractitionersserveadolescentsandadultwomen.

RegionalanalysesexaminetheprimarycareworkforceindifferentpartsofVermont,includingcountyandmulti-countyregions:NortheasternVermont,ChamplainValley,andSouthernVermont.

Thisreportisasnapshotofthenet changesintotalPCPsfromyeartoyearbetween2010and2012.Itspurposeistoidentifyareaswheretheprimarycareworkforceisadequateandwherethereareshortfalls.ThesupplyofpractitionersisexaminedbyprimarycarespecialtybothstatewideandwithinregionsofVermont.

benchmarks: How many Practitioners do we Need?

Forthis2012report,wearemaintainingthesamemethodasusedinpreviousyearsforanalyzingtheprimarycareworkforce,employingnationalbenchmarkstodeterminehowmanypractitionersareneeded.Astheprimarycareservicesevolveandasnewbenchmarksaredeveloped,1,2,3wewillupdateouranalyses(seeEndnotes,page13,forinformationonthecurrentmethod).Someofthefactorswhichputpressureonolderbench-marksincludetheimplementationofhealthcarereformsbothinVermontandnationally,whichwilllikelyincreasethenumberofpeoplewhowillbeseekingprimarycare.Demographicanalysesalsoshowanagingpopulationwhichisgenerallyassociatedwithincreasedneedformedicalcare.

Inthiseraofhealthcarereform,theorganizationofthehealthcaredeliverysystemisalsochanging.4Inthecurrentreport,weincludephysicians,advancedpracticeregisterednurses,physicianassistants,andcertifiednursemidwives.AsmoreVermontpracticesemployateamapproachtodelivercare,andasmoreprimarycarepracticesbecomemedicalhomes,additionaldisciplines(professions)mayneedtobeaddedtotheanalyses.ChangesinthedeliveryofcaremayalsochangetheroleofcurrentPCPs;thisshouldalsobereflectedinfutureworkforcebenchmarks.

Vermonthasseenaveryrapidadoptionofelectronicmedicalrecords(EMR)overthepastthreeyears.Whilethismayleadtoadvancesinsafetyandefficiencydowntheroad,theprocessofchoosing,installing,andlearningtouseanEMRtakesaconsiderablecommitmentoftimeandenergyonthepartofeverymemberofapractice.ItisnotyetclearifEMRadoptionwillleadtolongtermchangesinthecapacityofPCPsorprimarycarepractice.5

1. KuenningT.NegotiatedRulemakingCommittee:DesignationofMedicallyUnderservedPopulationsandHealthProfessionalShortageAreas.PresentedattheBi-StatePrimaryCare Meeting,Montpelier,VT,12/15/2011.2. www.healthworkforce.unc.edu/documents/PF_FAQ_Aug2012.pdf,11/26/2012.3. www.annfammed.org/content/10/6/503.full.pdf+html,12/5/2012.4. Bielaszka-DuVernayC.Vermont’sBlueprintforMedicalHomes,CommunityHealthTeams,andBetterHealthatLowerCost.HealthAffairs,2011;30(3):383-386.5. HillestadR,BigelowJ,BowerA,GirosiF,MeiliR,ScovilleR,TaylorR.Canelectronicmedicalrecordsystemstransformhealthcare?Potentialhealthbenefits,savings,andcosts. HealthAffairs,2005Sep-Oct;24(5):1103-17.

www.vtahec.org �

challenges: maintaining/increasing the Primary care workforce

Therearestillspecialchallengestomaintainingand,whereneeded,increasingtheprimarycareworkforceinVermont:

• financialandotherpressuresonhealthcaretrainees,includingmedicalstudentsandresidents,nursepractitioners,andphysicianassistants,tosub-specializeratherthanchooseprimarycare;

• reimbursementofandworkloadpressuresonprimarycarepractitioners;

• theagingofVermontprimarycarepractitioners,especiallyinternalmedicinephysicians;6

• theimpactoftheelderlypopulationbecominganincreasinglylargerproportionofthepopulation,asthisgroupisassociatedwithincreasedneedformedicalcare;and

• competitionfromotherstatesthatarealsoworkingtoincreasetheirprimarycareworkforce.

Ongoing work: Strengthening the Primary care workforce

ThereissignificantactivityunderwayinVermonttosupportdevelopmentofthenextgenerationofhealthcareworkers.ExamplesincludeAHEC’shealthcarecareerexplorationprogramsinmiddleandhighschool,andthesupportandengagementofhealthcareprofessionsstudentsattheUniversityofVermontandresidentsatFletcherAllenHealthCare.TheseprogramsencouragetraineestoconsiderfuturepracticeinhealthcareersinVermont.

TheVermontBlueprintforHealthisworkingtochangethewaywedeliverhealthcare,particularlyintheadvancedprimarycarepracticeinitiativewhichisprovidinganopportunitytoexplorenovelandmoreefficientwaystoimprovehealth.

Thereareconsiderablecommunityandstatewideactivitiesandprogramstohelprecruitandretaintheprimarycareworkforce,includingthestate-funded,AHEC-administeredVermontEducationalLoanRepaymentProgramforPrimaryCarePractitioners.Thesefundshelptoreduceapractitioner’seducationaldebtinexchangeforacommitmenttopracticeinVermont.Todate,overone-quarterofVermont’sprimarycarephysicianshavebenefittedfromthisprogram.

6. VermontDepartmentofHealth.2010PhysicianSurveyStatisticalReport,Burlington,VT,Aug2011.NOTE:Reportonthe2012surveyofindividualphysiciansisexpectedin2013.

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PrimArY cAre PrAcTiTiONerS – STATewide fiNdiNgS 2012

Primary care Practice Sites

In2012,therewere218primarycarepracticesitesinVermont,includingfamilymedicine,generalinternalmedicine,generalpediatrics,andgeneralobstetrics-gynecologysites.Practicesitesrangedinsizefromoneto18primarycarepractitioners(PCPs)persite(seeFigure1).About80%percentoftheprimarycarepracticeshadbetweenonetofiveindividualPCPs.ThemeanpracticesizewasfourindividualPCPs;themedianwasthreePCPs. EightypercentofthesitesincludedPCPswhopracticedthesameprimarycarespecialty.TwentypercentofpracticeshadPCPsrepresentingatleasttwoprimarycarespecialties,suchasfamilyandinternalmedicine,internalmedicineandpediatrics,pediatricsandobstetrics-gynecology,orothercombinations,includingPCPsfromallfourprimarycarespecialties. In2012,halfofallprimarycarepracticesinVermonthadatleastonefamilymedicinePCP.One-thirdhadatleastoneinternalmedicinePCP.Twenty-twopercentofthepracticeshadatleastonepediatricPCP.Twenty-twopercentofpracticeshadatleastoneobstetrics-gynecologyPCP. Halfoftheprimarycarepracticeswereprivatelyowned;one-quarter(28%)wereownedbyahospital;15%wereFederallyQualifiedHealthCenters(FQHCs);and6%wereRuralHealthClinics(RHCs).(SeeEndnotes,page13,foradditionalcriteriausedtodefineprimarycaresites.)

from individual Practitioners to fTes

In2012,therewere554individualMD/DOs,147individualAPRNs,35CNMs,and78PA-CspracticinginVermontprimarycarepractices,yielding814individualPCPs(seeTable1).Thiswasanetincreaseof27individualPCPsfrom2011.7TherewerenetincreasesinMD/DOs,APRNs,andCNMs,buttherewasnochangeinthenumberofindividualPA-Csfrom2011. Forcomparisonstonationalbenchmarks,thecountofindividualPCPs(see“No.PCPs”inTable1),wasconvertedtoFull-TimeEquivalents(FTEs)(see“No.inFTEs”inTable1)tostandardizethemeasurementofclinical time/effort.Thisisimportantsincetherearebothpart-timeandfull-timepractitionersatprimarycaresites.Part-timepractitionersmaybesplittingtheirclinicaltimeamongsmallruralsites,mayhaveonlypart-timeclinicalhourswiththebalanceoftheirtimedevotedtoadministrativeorresearchresponsibilities,ormaypracticepart-timeforotherreasons. In2012,combiningallprimarycarespecialties,theprimarycareworkforcegrewby15physicianFTEsand12APRNs,CNMs,andPA-CsFTEs(seeTable1,“SupplytoBenchmark”).

7. AreaHealthEducationCentersProgram(AHEC).TheVermontPrimaryCareWorkforce,2011Snapshot.Burlington,VT.Jan2012.

Table 1: All Primary care Practitioners by discipline

No. PcPs No. in fTes* discipline (2012) (2012)

Physicians(MD/DOs) 554 484

aPRns,cnMs,Pa-cs(combined) 260 175

Advanced Practice Registered Nurses (APRNs) 147 95

Certified Nurse Midwives (CNMs) 35 21

Certified Physician Assistants (PA-Cs) 78 60

Supply to benchmark

Supply in Supply in Supply in fTes* (2010) fTes* (2011) fTes* (2012)

-25 -35 -20

-7 -5 7

* smalldiscrepanciesareduetorounding

workforceshortage

50

40

30

20

10

1 2 3 4 5 6 7 8 9 10 11 12 13 15 18

figure 1: Number of PcPs* per Site (N=218 Sites)

* CountofindividualPCPswithoutregardtopart-orfull-time status.OnePCPattwoormoresitesiscountedateachsite.

Number Of PcPS Per SiTe

Number Of SiTeS

Table �: Primary care APrNs, cNms, and PA-cs by Specialty

No. APrNs, cNms, PA-cs Primary care Specialty (combined) in fTes* (2012)

Family Medicine 106

Internal Medicine 24

Obstetrics–Gynecology 29

Pediatrics 16

TOTalsTaTewiDe 175

* smalldiscrepanciesareduetorounding workforceshortage

Supply to benchmark


28 30 38

-37 -34 -35

7 6 10

-5 -6 -6

-7 -5 7

Table 2: Primary care Physicians by Specialty

No. md/dOs Primary care Specialty in fTes* (2012)

Family Medicine 202



Pediatrics 96

TOTalsTaTewiDe 484

Supply to benchmark


-2 -6 -2

-54 -58 -60

6 6 13

25 24 29

-25 -�5 -20


ForAPRNs,CNMs,andPA-Csinprimarycare,therewereincreasesin2012infamilymedicineandobstetrics-gynecology,asmeasuredinFTEs.However,therewaslittleornonetchangeininternalmedicineandpediatrics(seeTable3,“SupplytoBenchmark”).In2012,therewasashortfallofsixpediatricAPRNs/PA-Csandashortfallof35APRNs/PA-Csininternalmedicine.SinceAPRNsandPA-Csininternalmedicineserveadults,andAPRNsandPA-Csinfamilymedicinealsoserveadults(aswellaschildren),theAPRNs/PA-Csinfamilymedicinewereverylikelyoff-settingsomeoftheshortfallininternalmedicine.

NationalbenchmarkswereusedtodeterminethenumberofprimarycarepractitionersneededforanadequatesupplyofPCPs,whenappliedtotheVermontpopulation.Whenthe“SupplytoBenchmark”ispositive,thePCPsupplyisadequateforthepopulation.When“SupplytoBenchmark”isnegative,thereisashortfallofPCPs.PCPshortfallsarehighlightedinthetablesandmaps.(SeeEndnotes,page13,foradditionaldetailsonmethods.)

Primary care Practitioners by Specialty (in fTes)

Categorizingthestatewidetotalsbyprimarycarespecialty,thesupplyoffamilymedicinephysiciansinFTEswasclosetoadequatestatewidein2012.Thesupplyofobstetrician-gynecologistsandpediatricianswasadequate.EachoftheseprimarycarespecialtiesalsoshowednetimprovementinphysicianFTEsfromtheprioryear(seeTable2,“SupplytoBenchmark”).However,thetrendforgeneralinternalmedicinephysicians,whoserveadults,continuedtodeclinefrom2010to2012.In2012,therewasashortfallofsixtyinternalmedicinephysicianFTEs.

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Combiningphysicians(seeTable2)withAPRNsandPA-Cs(seeTable3)ininternalandfamilymedicine,theoverall increase in all PCPs in 2012 did not improve the area of greatest need in Vermont: primary care services for adults.FurtherevidenceoftheneedforPCPsinadultprimarycareispresentedintheregionalsectionsofthisreportinTables10,11and12(seepages10-12).

limiting New Patients by Specialty

TheincreaseinprimarycarephysicianFTEs,inthe2012aggregate,wasassociatedwithasmalldeclineinphysicianslimitingorclosingtheirpracticetonewpatients(seeTable4,“TotalStatewide”).Thismayindicateareversalofthetrendwehavebeenobservingsince2009,8when34%ofphysicianswerelimitingorclosingtheirpracticetonewpatients.Thisroseto36%in2010and43%2011,butdeclinedto40%in2012.

Table 5: Primary care APrNs, cNms, and PA-cs limiting or No longer Accepting New Patients by Specialty

Primary care % APrNs, cNms, PA-cs % APrNs, cNms, PA-cs % APrNs, cNms, PA-cs Specialty limiting/Not Accepting (2010) limiting/Not Accepting (2011) limiting/Not Accepting (2012)

Family Medicine 35% 38% 32%

Internal Medicine 36% 53% 61%

Obstetrics–Gynecology 14% 14% 5%

Pediatrics 26% 39% 7%

TOTalsTaTewiDe 31% 36% 28%

Table �: Primary care Physicians limiting or No longer Accepting New Patients by Specialty

Primary care % md/dOs limiting/ % md/dOs limiting/ % md/dOs limiting/ Specialty Not Accepting (2010) Not Accepting (2011) Not Accepting (2012)

Family Medicine 43% 51% 47%

Internal Medicine 54% 68% 66%

Obstetrics–Gynecology 6% 17% 15%

Pediatrics 22% 12% 13%


Whilethereweresmallimprovementsin2012inmostoftheprimarycarespecialties,still almost half the family medicine physicians and two-thirds of the internal medicine physicians in Vermont limited or closed their practice to new patients in 2012.Limitationsincludedonlyacceptingnewpatientsiftheylivedinthepracticetownorifafamilymemberwasalreadyapatientatthepractice. Similartothephysiciantrend,ansomeincreaseinthenumberofAPRNs,CNMs,andPA-CswasassociatedwithsomedeclineinthepercentofthesePCPslimitingorclosingtheirpracticetonewpatients(seeTable5,“TotalStatewide”).Alsosimilartothephysiciantrend,thegreatestpercentofthesePCPslimitingorclosingtheirpracticetonewpatientswasforAPRNsandPA-Csininternalandfamilymedicinepractices.

8. AreaHealthEducationCentersProgram(AHEC).TheVermontPrimaryCareWorkforce,2009Snapshot.Burlington,VT.Jan2010.

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Table �: Primary care Physicians by county

Population No. Practice No. md/dOs county (est. 2011) Sites (2012) in fTes* (2012)

nORTheasTeRnveRMOnT

Caledonia 31,166 11 24

Essex 6,291 2 2

Lamoille 24,701 10 19

Orange 29,006 8 20

Orleans 27,173 10 22

Washington 59,626 19 51

chaMPlainvalley

Addison 36,742 11 25

Chittenden 157,491 50 141

Franklin 48,113 21 30

Grand Isle 6,931 2 1

sOuTheRnveRMOnT

Bennington 36,970 19 30

Rutland 61,289 18 41

Windham 44,266 21 38

Windsor 56,666 16 39

TOTalsTaTewiDe 626,431 218 484

* smalldiscrepanciesareduetorounding workforceshortage.

Supply to benchmark


-15 -9 -5

1 -1 -1

-3 -3 -3

-2 -1 -1

-5 -3 -3

-5 -4 0

-1 3 3

5 -7 -3

3 -1 -4

18 6 15

-10 -8 -9

-5 -4 -5

-14 -19 -12

0 -3 1

-12 -10 -8

5 5 3

-7 -11 -7

-25 -35 -20

Primary care Practitioners by region (in fTes)

Examiningtheprimarycarephysicianshortfallsbyregionsofthestate,eachoftheAHECregionsreflectedthestatewidetrendandshowedsomeimprovementinthetotalnumberofprimarycarephysicianFTEsin2012,thoughashortfallpersistedineachregion(seeTable6,“SupplytoBenchmark”forNortheasternVT,ChamplainValley,andSouthernVT).Despite the overall increases since 2011, the need for primary care services for adults within each region continued in 2012,asshowninfurtherregionalbreakdownsbyspecialtyinTables10,11and12(seepages10-12).

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Table 7: Primary care APrNs, cNms, and PA-cs by region by county

No. APrNs, cNms, PA-cs county (combined) in fTes* (2012)

nORTheasTeRnveRMOnT

Caledonia 10

Essex 2

Lamoille 7

Orange 9

Orleans 9

Washington 20

chaMPlainvalley

Addison 9

Chittenden 41

Franklin 13

Grand Isle 2

sOuTheRnveRMOnT

Bennington 9

Rutland 15

Windham 12

Windsor 15

TOTalsTaTewiDe 175


Supply to benchmark


7 8 11

1 1 2

0 0 1

0 0 1

0 1 1

4 3 2

2 3 4

-13 -12 -2

-3 -4 -1

-7 -10 -2

-3 1 0

0 -1 0

-2 -1 -2

-3 0 -1

0 1 -2

3 0 0

-2 -2 0

-7 -5 7

Inthesix-county,northeasternregionofVermont,whichhastraditionallyhadthehighestneedforprimarycarePCPs,physicianFTEsimprovedfrom2010to2012.ThegreatestoverallneedforprimarycarephysicianscontinuedinEssexandOrangeCounties(seeTable6).TheregionhadanadequatesupplyofAPRNs,CNMs,andPA-Cscombiningspecialties,andthesupplycontinuedtostrengthenfrom2010to2012(seeTable7).Furtheranalysesbyspecialtywithintheregion,includingshortfallsinadultprimarycare,arepresentedinTable10(page10). InthefourChamplainValleycounties,theimprovedphysicianFTEsin2012weredrivenbyimprovementsonlyinChittendenCounty.TherewassomedeclineinphysicianFTEsinAddison,Franklin,andGrandIsleCounties.ThegreatestoverallneedintheregionforprimarycarephysicianscontinuedinFranklinCounty(seeTable6).TheregionshowedanimprovementinthesupplyofAPRNs,CNMs,andPA-Csacrossprimarycarespecialties,withthegreatestimprovementsinChittendenCounty,followedbyAddisonCounty(seeTable7).Furtheranalysesbyspecialtywithintheregion,includingshortfallsinadultprimarycare,arepresentedinTable11(page11).

In2012,thenumberofAPRNs,CNMs,andPA-CsinFTEsshowedimprovementintheNortheasternandChamplainValleyregions,buttherewaslittlechangeinSouthernVermontcombiningallprimarycarespecialties(seeTable7,“SupplytoBenchmark”).

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Table �: Primary care Physicians limiting or No longer Accepting New Patients by county

% md/dOs limiting/ % md/dOs limiting/ % md/dOs limiting/ county Not Accepting (2010) Not Accepting (2011) Not Accepting (2012)

Northeastern Vermont 55% 51% 43%

Champlain Valley 31% 40% 42%

Southern Vermont 29% 40% 35%


ThefoursoutherncountiesofBennington,Rutland,Windham,andWindsorcombinedtobetheregionwiththegreatestneedforprimarycarephysiciansinVermontin2012.ThiswasdrivenbyhighneedsinRutlandandWindsorCounties,whencombiningallprimarycarespecialties.Despitetheseneeds,mostcountiesintheregionshowedsomeimprovementinthenumberofphysicianFTEsfrom2011to2012(seeTable6).ThesupplyofAPRNs,CNMs,andPA-Csintheregionwasclosetoadequatein2012,withRutlandCountyexperiencingthegreatestneed(seeTable7).Furtheranalysesbyspecialtywithintheregion,includingshortfallsinadultprimarycare,arepresentedinTable12onpage12.

limiting New Patients by region

From2011to2012,theoverallimprovementinthetotalnumberofprimarycareMD/DOs,APRNs,CNMs,andPA-CswasgenerallyassociatedwithadeclineinthepercentofPCPslimitingornotacceptingnewpatients(seeTables8&9).Therewasalsolessvariabilitybetweentheregionsin2012,comparedto2010.

Table �: Primary care APrNs, cNms, and PA-cs limiting or No longer Accepting

New Patients by county

% APrNs, cNms, PA-cs % APrNs, cNms, PA-cs % APrNs, cNms, PA-cs county limiting/Not Accepting (2010) limiting/Not Accepting (2011) limiting/Not Accepting (2012)

Northeastern Vermont 44% 38% 26%

Champlain Valley 24% 38% 32%

Southern Vermont 22% 33% 25%


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2 0 1 2 S u r v e Y f i N d i N g S b Y A H e c r e g i O N

• PrimaryCarePracticeSite

NortheasternVermontcaledonia, essex, lamoille, Orange, Orleans, and washington counties

In2012,therewere60primarycarepractices(seeadjacentmap)inthissix-countyregionof177,963Vermonters.The150primarycarephysiciansand88APRNs,CNMs,andPA-Cscombinedtoyieldatotalprimarycareworkforceof238individualpractitioners.

Supply and distribution by county (in fTes)

From2010to2012,combiningallprimarycarespecialties,thesupplyofprimarycarephysicians,APRNs,CNMs,andPA-Csshowedimprovement(seeTables6&7).In2012,thegreatestoverallneedforprimarycarephysicianscontinuedinEssexandOrangeCounties.TheregionhadanadequatesupplyofAPRNs,CNMs,andPA-Csacrossprimarycarespecialties.TheseimprovementswerefurtherreflectedinthedecliningproportionofPCPsintheregionreportingthattheirpracticeswereeitherlimitedorclosedtonewpatientsfrom2010to2012(seeTables8&9).

Supply and distribution by Specialty (in fTes)

Examiningprimarycarephysiciansupplybyspecialty,therewassomeimprovementacrossallspecialties(seeTable10).However,in2012,therecontinuedtobeashortfallofprimarycarephysiciansforadults(combiningfamilyandinternalmedicine)inCaledonia,Essex,andOrangecounties,asillustratedinthesmallmapatthebottomofthispage.

Washington

Orange

Caledonia

LamoilleOrleans

Essex

•Northeastern vermont AHec

Supply to benchmark


2.5 5 6

-18 -18 -15

-1 2 0

0 3 4



Family Medicine 64



Pediatrics 23


PcPs limiting or Not Accepting New Patients

Inprioryears,highneedforPCPsinthisregionwasassociatedwithahigherpercentofPCPslimitingorclosingtheirpracticetonewpatients,comparedtothestatewideaverage.AsthetotalnumberofPCPsinthisregionhasimproved,thepercentlimitingorclosingtheirpracticetonewpatientshasimproved,i.e.,decreased(seeTables8&9).In2012,57%offamilyandinternalmedicinephysiciansand36%offamilyandinternalmedicineAPRNsandPA-Csinthisregionlimitedorclosedtheirpracticetonewpatients.

Workforce shortage in internal and family medicine physicians combined

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ChamplainValleyAddison, chittenden, franklin, and grand isle counties

In2012,therewere84primarycarepractices(seeadjacentmap)inthisfour-countyregionof249,277Vermonters.The236primarycarephysiciansand93APRNs,CNMs,andPA-Cscombinedtoyieldatotalprimarycareworkforceof329individualpractitioners.


Theregionshowedimprovementinthetotalnumberofphysiciansacrossprimarycarespecialties(seeTable6),butthiswasdrivenbyincreasesinChittendenCountyandsomedeclineinAddison,Franklin,andGrandIsleCounties.ThegreatestneedscontinuedinFranklinCounty.Theregionhasshownanincreaseintheproportionofprimarycarephysiciansreportingthattheirpracticeswerelimitedorclosedtonewpatientssince2010(seeTable8).

TherewereimprovementsinthesupplyofAPRNs,CNMs,andPA-Csacrossprimarycarespecialties,withthegreatestimprovementsinChittenden,followedbyAddisonCounty(seeTable7).ThiswasassociatedwithadeclineintheproportionofthesePCPsreportingtheirpracticeslimitedorclosedtonewpatientssince2011(seeTable9).


Examiningprimarycarephysiciansbyspecialty,obstetrics-gynecologyphysiciansshowedthemostimprovement(seeTable11).Thesupplyofpediatriciansremainedadequate.Butthesupplyofphysiciansforadults,includingfamilyandinternalmedicine,continuedtoshowaveryhighneed.Asillustratedonthesmallmapatthebottomofthispage,everycountyintheregionhadashortfallofphysicianstoserveadultsinprimarycarein2012.

Franklin

Chittenden

Addison

•

Grand Isle

•champlain valley AHec

Supply to benchmark


-12 -16 -15

-14 -17 -19

10 8 13

21 17 18



Family Medicine 66



Pediatrics 44



In2012,59%offamilyandinternalmedicinephysiciansand41%offamilyandinternalmedicineAPRNsandPA-Cslimitedorclosedtheirpracticetonewpatientsinthisregion.


12 www.vtahec.org


SouthernVermontbennington, rutland, windham, and windsor counties

In2012,therewere74primarycarepractices(seeadjacentmap)inthisfour-countyregionof199,191Vermonters.The168primarycarephysiciansand79APRNs,CNMs,andPA-Cscombinedtoyieldatotalprimarycareworkforceof247individualpractitioners.


Thisregionshowedthegreatestneedforprimarycarepractitionersfrom2010to2012.WhileBennington,Rutland,andWindsorCountiesshowedsomeimprovementsince2011inthetotalnumberofprimarycarephysicians,RutlandandWindsorCountiescontinuedtoshowthegreatestneedsintheregionin2012(seeTable6).RutlandalsoshowedthegreatestneedintheregionforAPRNs,CNMs,andPA-Cs(seeTable7).In2012,combiningallprimarycarespecialties,PCPsshowedimprovementintheproportionlimitingorclosingtheirpracticetonewpatients(seeTables8&9).


Examiningprimarycarephysiciansbyspecialty,in2012,therewereimprovementsinphysiciansupplyinfamilymedicine,obstetrics-gynecology,andpediatrics,butadeclineininternalmedicinephysicians(seeTable12).Asillustratedonthesmallmapatthebottomofthispage,everycountyintheregionhadashortfallofphysiciansinadultprimarycare(combiningfamilyandinternalmedicinephysicians).

•

Windham

WindsorRutland

Bennington

• Primary Care Practice Site

Southern vermont AHec



Supply to benchmark


8 5 7

-22 -24 -26

-3 -4 -0.5

3 4 7



Family Medicine 72



Pediatrics 29



In2012,47%offamilyandinternalmedicinephysiciansand35%offamilyandinternalmedicineAPRNsandPA-Cslimitedorclosedtheirpracticetonewpatientsinthisregion.

www.vtahec.org 1�

Primary care Practice:Anofficeorclinicwhichofferedgeneralprimarycaretoadultsand/orchildren,anongoingrelationshipbetweenaprimarycarepractitioner(PCP)andthepatient,comprehensivecare,continuityofcare,andcoordinationofcareinfamilymedicine,generalinternalmedicine,generalobstetrics-gynecology,andgeneralpediatrics.Sitemayhaveincludedthepatient’shomeforan“allhomecare”primarycarepractitioner.

Sitesnotincludedwere:walk-in/immediate/acutecareclinics,school-basedclinics,freeclinics,PlannedParenthoodclinics,collegehealthcenters,DepartmentofCorrectionshealthfacilities,sitesforat-riskyouth,sitesforhomelesspeople,nursinghomes,residentialassisted-livingfacilities,andVeteransAdministrationclinics.

Primary care Practitioners:PCPsincludedphysicians(MDsandDOs),advancedpracticeregisterednurses(APRNs),certifiednursemidwives(CNMs),andcertifiedphysicianassistants(PA-Cs)atprimarycarepracticesites.

Practice-based Survey:Primarycareofficeadministratorsfromall218primarycarepracticesinVermontweresurveyedbyAHECinthespring/earlysummerof2012,toupdatetheprioryear’slistofPCPsandtoreporttheircurrent,typical,weeklyofficehoursatthepracticesite.PerdiemorothertemporaryPCPswerenotincluded,ifthepracticewassearchingforapermanentpractitioner.

measuring the Primary care workforce: MeasurementoftheprimarycareworkforcewasguidedbystandardsfromtheGraduateMedicalEducationNationalAdvisoryCommittee(GMENAC)andtheHealthResourcesandServicesAdministration(HRSA)oftheU.S.DepartmentofHealthandHumanServices.

calculating Physician full-Time equivalents (fTes): OneFTEwas40hoursperweek.UsingamethoddevelopedbyHRSA9tomeasurephysicianshortageareasingeographicregions,physicianin-officepatienthourswereadjustedtoreflectadditionaltimefor:diagnosis,treatment,andclinicalreportsinthecourseofdirectpatientcare;timespentoutsideoftheoffice,atahospital,nursinghome,emergencydepartmentorcaredeliveredinthepatient’shome.Theamountofadjustmentdifferedbyprimarycarespecialty(seeTable13).Allcalculationswereextendedtotwodecimalplaces(100thsplace).NophysicianexceededoneFTE.

Table 1�: HrSA Physician fTe methodology

Primary care Office Adjustment Hours full-Time Specialty Hours factor Per week equivalent

Family Medicine # x 1.4 ÷ 40 = FTE

Internal Medicine # x 1.8 ÷ 40 = FTE

Obstetrics–Gynecology # x 1.9 ÷ 40 = FTE

Pediatrics # x 1.4 ÷ 40 = FTE

calculating APrN, cNm, PA-c full-Time equivalents (fTes):OneFTEwas40hoursperweek.WeeklyhoursforeachofthesePCPsweredividedby40.Allcalculationswereextendedtotwodecimalplaces(100thsplace).NopractitionerexceededoneFTE.

reporting fTes: Small discrepancies due to rounding: WhileallFTEcalculationswerecarriedouttothehundredthsplaceandthenaggregatedbydiscipline,region,andprimarycarespecialty,thereaderwillfindwholenumbersinthecharts.Oftenthiscreatedsmalldiscrepanciesincolumntotals.Thesediscrepancieswereduetoroundinguptowholenumbers.Forexample,while24.40+25.40+25.40+25.30=100.40,inthisreporttheseaggregatednumberswerepresentedas24+25+25+25=100.

benchmark to identify Adequacy and Shortage:AHECusedguidelinesfromGMENAC10forthenumberofprimarycarephysicians(inFTEs)perpopulation11foreachprimarycarespecialty:

Table 1�: gmeNAc Physician recommendations

Family Medicine 32.5 FM physicians per 100,000

Internal Medicine 28.1 IM physicians per 100,000

Obstetrics–Gynecology 9.2 OB-GYN physicians per 100,000

Pediatrics 10.7 PED physicians per 100,000

BasedonGMENACassumptionsofanadditionalthree-tenthsofanAPRN/CNM/PA-Cforeveryprimarycarephysician,theVermontDepartmentofHealthhasconsidereditashortageifthereislessthanoneofthesePCPsforeverythreeprimarycarephysicians,althoughservicedeliverymodelsvarybyregion.

Shortagesweredefinedasoneormorepractitionersbelowthebenchmarkssetforthbydiscipline,region,andprimarycarespecialty.

eNdNOTeS

9 http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/medicaldentalhpsaguidelines.html.Jul2012.10.U.S.DepartmentofHealthandHumanServices,HealthResourcesAdministration:ReportoftheGraduateMedicalEducationNationalAdvisoryCommittee(GMENAC) Vol.1:SummaryReport.DHHSPubNo.(HRA):81-651.U.S.GovernmentPrintingOffice,Washington,D.C.1980.11.http://quickfacts.census.gov/qfd/states/50000.htm.Jul2012.

Connecting students to careers, professionals to communities, and communities to better health.

For more information contact your regional AHEC or

Elizabeth Cote, Director

[email protected]

(802) 656-0030

www.vtahec.orgJanuary2013

Primary care Survey

PRACTICENAME DATEOFCOMPLETION

PHySICALTOWNOFPRACTICE

CONTACTPERSON CONTACTEMAIL CONTACTTELEPHONE

PracticeSiteOwnership: FQHC RHC Hospital-owned Privatepractice

PleaseincludeallMDs,DOs,APRNs,CNMs,andPA-Cswhoseepatientsatyourpracticesite.Indicateofficehours,notincludingcall,roundsoradministrativetime.

Practitioner degree/ Specialty in-Office Patient Accepting New Patients? Name certificate Hours Per week Yes No limited to:

the vermont primary care workforce

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