NEW J E RSEY PHYSICIAN WORKFORCE

TASK FORCE REPORT

A Report by:

New Jer sey Cou ncil of

Teaching Hospitals

J . Richard Golds tein, M.D.,

Presiden t

Debora h S. Briggs, BSN, MBA, Senior Vice Presiden t,

Health Policy an d Advocacy

Workforce Policy Task Force Organizations Represented by Workforce Policy Task Force Members Advisory Graduate Medical Education Council B. Lynch Associates Board of Medical Examiners Center for State Health Policy, Rutgers University Committee of Interns & Residents/SEIU Healthcare Medical Society of New Jersey Assemblyman Herb C. Conaway, Jr., M.D. New Jersey Hospital Association Senator Joseph F. Vitale NJ Area Health Education Center NJ Department of Banking & Insurance NJ Department of Health & Senior Services NJ Department of Human Services Seton Hall School of Graduate Medical Education The Matos Group Touro University College of Medicine University of Medicine and Dentistry, New Jersey University of Medicine and Dentistry, New Jersey - Robert Wood Johnson Medical School Consultants: Center for Health Workforce Studies- University at Albany Association of American Medical Colleges, Center for Workforce Studies

Brenna Snider, Research and Editorial Consultant

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Acknowledgements Many thanks to New Jersey Hospital Association for co-sponsoring this important project. The New Jersey Council of Teaching Hospitals would like to thank the following individuals for their time and expertise in Task Force deliberations: Linda Anderson J1 Visa Program Department of Health and Senior Services Dr. Howard Rabinowitz, MD Director, Physician Shortage Area Program Jefferson Medical College Thomas Jefferson University David Squire, Executive Director Utah Medical Education Council Melanie Taylor, Deputy Director Utah Medical Education Council Cheri Tucker, Executive Director Georgia Board for Physician Workforce Colette Caldwell, Statistical Research Analyst Georgia Board for Physician Workforce

About the New Jersey Council of Teaching Hospitals

New Jersey Council of Teaching Hospitals (Council) is the State’s premier teaching hospital network. Founded in 1986 to recognize the unique nature and special needs of teaching hospitals, this non-profit consortium consists of Atlantic Health, Cooper University Hospital, Hackensack University Medical Center, Meridian Health, Saint Barnabas Healthcare System, St. Joseph's Regional Medical Center, Somerset Medical Center, UMDNJ-University Hospital, University of Medicine and Dentistry of New Jersey, Catholic Health East/NJ, and Saint Peter's University Hospital.

Together, the Council institutions represent more than 36,000 health care professionals and about 7,000 hospital beds; care for more than 414,000 inpatients and nearly 4.7 million outpatient visits each year which account for over 1.9 million patient days; total an aggregate budget in excess of $5.7 billion per year; and provide a significant amount of the state's charity care while constituting less than 20 percent of the state's hospitals. Two of New Jersey's Level I Trauma Centers are NJCTH hospitals, as are four of the state's seven Level II Trauma Centers.

Council member institutions are dedicated not only to high-quality patient care, but to health professions education and sophisticated research as well. NJCTH hospitals train more than 1,500 resident physicians each year and work with a variety of medical schools.

The Council’s mission as an organization is to provide leadership in the development of Centers of Excellence in health care delivery, education, and research, and to serve as the optimal setting for the provision of outstanding patient care and for the education of health care professionals.

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Executive Summary

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Executive Summary

The New Jersey Council of Teaching Hospitals (Council), together with New Jersey’s departments of Health and Senior Services (DHSS), Banking and Insurance (DOBI), Human Services (DHS), New Jersey Hospital Association, Medical Society of New Jersey, and numerous private organizations in 2007 established a Physician Workforce Policy Task Force (Task Force). The charge of the Task Force was: To undertake a needs assessment of current and future physician supply and demand, as

well as distribution of physician practices across the state. To identify issues and barriers that impede the medical schools, teaching hospitals, state

agencies, and “the market” at large in addressing physician shortages. To recommend specific strategies that address and correct health workforce shortfalls to

ensure adequate access to health care services for New Jersey citizens for the next decade. Findings New Jersey is facing significant future shortages in both primary care and several specialty areas. In eleven years (2020) there is a projected shortfall of over 2,800 additional physicians beyond the current physician graduate medical education (GME) production pipeline representing a 12 percent gap in the physician supply versus the likely population demand for services. The shortage consists of approximately 1,000 primary care physicians and 1,800 specialists. Based on existing publications from the Rutgers Center for State Health Policy on physician workforce supplies, the DHSS on prenatal services, the scrubbed American Medical Association (AMA) databases, national physician ratios by specialty, and numerous other data sources, the Task Force concluded that there is a current shortage within primary care specialties, including family medicine, geriatrics, general surgery, and obstetrics. Within non-primary care specialties, neurosurgery and pediatric sub-specialties are the most alarming. Over seventy percent of all pediatric sub-specialties have serious shortages. To ensure New Jersey citizens have access to necessary physicians and clinical services in the future, the State of New Jersey, the medical schools, and all the teaching hospitals will need to form a centralized strategic planning alliance to ensure policy, regulations, funding, and recruitment/retention programs are put in place to manage the physician supply. The Study Process The Council retained the Center for Health Workforce Studies of the University at Albany (CHWS), who secured the forecast modeling expertise of the Lewin Group and Altarum Institute, to perform extensive review and modeling of the AMA Masterfile of Physicians, the New Jersey Board of Medical Examiners database, the AMA Resident database, the New Jersey Department of Labor and Workforce Development data, and the New Jersey Resident Exit Survey results. The Council embarked on parallel research of the Association of American Medical Colleges (AAMC) physician workforce data, other state health workforce activities, national physician to population ratios, and performed extensive literature searches to assess issues and proven solutions addressing physician shortages. The Council’s Physician Workforce Policy Task Force, which interfaced with the project consultants, refined the baseline supply model and then defined the “Most Likely Demand

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Scenario” from 2009 to 2020, weighing the most significant variables (health care reform, insuring the uninsured, New Jersey’s economic growth, and increased efficiencies in the provision of medical care). After months of deliberation, the Task Force determined the following assumptions should be reflected in New Jersey’s physician supply “most likely demand model:” Health care reform will begin by 2012, leading to major infrastructure, policy, and funding

reforms by 2020. The current 250,000 uninsured children will be reduced steadily between 2009 to less than

25,000 by 2020. Uninsured adults will be reduced from the current 1,150,000 adults in 2009 to approximately

345,000 by 2020. The remaining uninsured will include New Jersey’s undocumented immigrants and individuals who choose not to participate in available insurance programs.

New Jersey’s economic growth will decline by 2 percent in 2009 and will remain negative until 2013; thereafter, the economic growth incrementally improves reaching 2.5 percent economic growth by 2020.

Clinical service efficiencies will occur, including the reduction of excess clinical tests and procedures; elimination of redundant diagnostic tests; enhanced communication through the use of information technology; and implementation of electronic health records. Together these reforms will improve efficiencies by 2.5 percent by 2020.

This “Most Likely Demand Scenario” was then modeled against the baseline.

Table 1: Most Likely Demand Scenario 2008 Current Supply*

2020 Projected Supply**

Projected Shortage

By 2020***Baseline Supply Physician production, practice patterns, rates of separation from workforce, and migration patterns remain constant

TOTAL PRIMARY CARE SPECIALISTS Anesthesiology Cardiovascular Diseases Emergency Medicine General Internal Medicine General Pediatrics General Surgery General/Family Medicine Obstetrics & Gynecology Ophthalmology Orthopedic Surgery Other Int. Med. Subspecialties Pediatric Subspecialties **** Other Specialties Other Surgical Specialties Otolaryngology Pathology Psychiatry Radiology Urology

22,410

8,233 14,177

1,406 1,013

780 3,825 2,539

620 1,869 1,353

614 685

2,007 536

1,170 784 259 341

1,302 961 346

24,697

9,020 15,697

1,612 1,269

897 4,424 2,944

999 2,228 1,528

693 770

3,179

1,428 576 274 440

1,532 1,110

373

-2,835 -1,006 -1,829

-188 -118

36 -526 -67

-181 -412 -43 -66

-105 -720

-16 -70 -35 -57 -56

-139 -70

* Amounts include only post-residency, patient care physicians, which is about 94% of all licensed physicians (23,748).

** The amounts for Total, Primary Care, and Specialists were adjusted to take into account surpluses/shortages that likely exist (currently) in some specialty areas. The unadjusted baseline supply for 2020 is 26,274 (9,596 primary care; 16,678 non-primary care).

*** The projected shortages are based on adjusted 2020 Projected Baseline Supply. **** Pediatric Subspecialists supply and demand data can be found on Appendix 10.

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Insights Regarding Physician Data and the Determination of Supply and Demand The Task Force became frustrated with the absence of data to provide critical information which would clarify specific physician shortages, such as whether the practicing OB/GYN physicians in the state are actually performing deliveries. This lack of data created other negative consequences relating to qualifying for J-1 visa positions and federal loan repayment funding that the Task Force believed could be rectified if New Jersey instituted a mandatory re-licensure survey. This survey would provide vital data that could guide policy and funding decisions impacting future physician supply. Our goal was to identify the needed supply of primary care and specialty physicians over the next eleven years. The sophisticated forecasting models utilizing the CHWS and the Lewin Group provided baseline targets, but it was soon realized it is impossible to mathematically calculate several “unknowns” that will impact physician supply and demand in the future. These include the outcomes derived by federal and state health reform initiatives, the success of the Obama administration in restoring economic growth through the federal stimulus package, the impact of deploying IT integration and electronic medical records, the success of increasing the health care workforce through educational grants, and the ability to improve cost efficiency and clinical effectiveness through these broad based reforms. Nonetheless, New Jersey’s need is daunting, with deficits in the best case scenario being a shortfall of 2,500 primary care and specialty physicians, beyond the current pipeline. The worst case scenario demonstrates the need of more than 3,100 physicians by 2020. With this variable target, the Task Force prioritized as the most important action, the creation of a central entity within the state to continually monitor and forecast supply and demand, as well as to manage and refine policy, programs, and strategies. A very deliberate, multi-faceted strategic action plan must be implemented expeditiously. Figure 1 provides an example of a multi-faceted policy and programmatic approach that could significantly address New Jersey’s impending physician shortage. Figure 1 – Example of a Programmatic “Menu” to Address Physician Shortages

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The Task Force’s Recommendations

Goal I: Create or designate an organization, the “Center for Medical and Health Workforce Planning,” to continuously monitor, forecast, predict, and refine recommendations to ensure an adequate and well-dispersed supply of physicians and advanced practice practitioners for New Jersey.

The Center will be responsible to perform (or subcontract with an entity to perform) the collection, analysis of multiple data sources, and comprehensive reporting on health workforce supply and demand trends. With this information the Center will guide the allocation of resources based on workforce needs, track physician and advanced practice provider shortages to determine graduate medical education (GME) and other funding priorities, manage “vacant” resident positions, direct funds to the individual programs with greatest impact on workforce needs, and provide incentives for teaching programs to retain graduates to practice in New Jersey. This Center would interface with the National Health Workforce Advisory Council to submit data and obtain federal grants that will support New Jersey’s health workforce initiatives.

Goal II: Expand retention and recruitment initiatives to encourage physicians to enter, remain in, or return to practice in New Jersey.

New Jersey is competing with forty-nine states to recruit new physicians, as they address their state’s physician workforce shortages. New Jersey must expand current workforce programs, improve New Jersey’s practice environment, and establish financial incentives which offset the high cost-of-living and small business barriers inherent to the state, to be competitive. Our goal must be to foster innovation within existing programs and make certain we maximize federal programs and funding to ensure New Jersey is a viable state to practice medicine.

Goal III: Align goals and incentives between the medical education stakeholders: medical schools, teaching hospitals, and the State of New Jersey.

Reforms should focus on establishing strategic planning processes between the state, teaching institutions, and medical education leadership. Using data from forecasting models and data driven reports created by “the Center,” all stakeholders should work to ensure the medical education system is maintained or supported, the physician specialty training programs and residency counts are adjusted to address future physician workforce shortages by specialties, and collaborate on strategies to increase in-state retention.

Goal IV: Enhance state funding for medical education and post graduate physician residency programs.

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Graduate medical education in New Jersey cost $765 million in 2007. Of this, state Medicaid GME funding is only $60 million (including the federal matching dollars). Medicare funds approximately $340 million, leaving the balance to be paid by hospitals from foundation funds and operational margins. This Goal focuses on identifying sources for adequate funding that will then allow New Jersey to be more competitive. New Jersey must attract more students by increasing medical school capacity, it must adequately fund graduate medical training positions, it must address student medical education debt levels through viable programs, and the practice environment must be improved to retain or attract physicians seeking to establish their medical practice in this state.

Goal V: Pursue federal reforms to address expanding GME resident slots to address workforce shortages, as well as systemic problems in GME funding mechanisms, administrative processes, and regulatory oversight.

Medical education and healthcare workforce needs have changed over the past 15 years, while regulations and funding have not. For example, more training takes place in an outpatient setting; however, Medicare GME reimbursement is primarily inpatient drive. As the training model changes, the reimbursement methodology must be reformed. Additionally, the oversight system is over-complicated with costly rules and regulations that thwart logic and stifle innovation. GME resident position expansion, administrative, and funding systems must be addressed as national health system reform is being contemplated in Washington, D.C. Conclusion Ensuring that New Jersey has an adequate physician supply will not be easy. The physician shortage is a national problem, albeit less so in states that have established policies and programs to address their physician training and practice environment. Utah, Georgia, and other states have implemented state-financed physician retention and recruitment programs with documented success. New Jersey has several retention programs, but these initiatives function autonomously and are poorly funded. Meeting the five goals will require state and federal commitment, public and private partnerships, as well as significant “political will” and health leadership engagement, to address system improvements, identify funding sources, and establish recruitment and retention programs. Medical schools, teaching hospitals and academic medical centers, and state agencies must be willing to embrace change, reject traditional thinking, and participate in on-going give and take in reform discussions. If these parties are successful, we can be assured that New Jersey’s future physician and health care workforce will be able to meet the clinical and health care needs for all New Jersey citizens.

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Table of Contents Tables and Figures Regional Definitions Introduction Section One

New Jersey’s Current Physician Workforce

Section Two

New Jersey’s Medical Education Pipeline

Section Three

A Summary of New Jersey’s Current Physician Supply

Section Four

Future Physician Need in New Jersey

Section Five

Task Force Recommendations

End Notes Appendices

1. Acronym and Abbreviation Guide 2. Physician Mapping Document 3. Physician Supply and Distribution in New Jersey, 2008 (provided by CHWS) 4. Physician-to-Population Ratios Benchmarking Analysis (NJCTH) 5. Comparison of 2001-2006 New Jersey Patient Care Physicians by Specialty per 100,000 (Rutgers

CSHP) 6. Selected Recommendations of the New Jersey Health Care Access Study Commission 7. New Jersey Health and Senior Services- Medically Underserved Index 8. State Examples of Health Care Workforce Initiatives 9. Center for Medical and Health Workforce Planning, Utah and Georgia Models 10. New Jersey Pediatric Subspecialist Workforce

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Tables and Figures Tables:

Table 1: Most Likely Demand Scenario Table 2: New Jersey Active Patient Care Physicians, 2008 Table 3: Unmet Need of Family Medicine Physicians in New Jersey Table 4: Perceived Specialty Shortages and Surpluses of Physicians Table 5: Pediatric Sub-specialist Shortages in New Jersey, 2008 Table 6: Percentage of Active Physicians Who Are IMGs (Northeast), 2007 Table 7: Medical Education Comparison, 2006/07 Table 8: Number of New Jersey Residents/Fellows by Specialty, 1995/96 and 2006/07 Table 9: Origins of Physicians Training in New Jersey, 2006/07 Table 10: Comparison of Retention Rates in Surrounding States Table 11: Controllable vs. Uncontrollable Lifestyle Specialties Table 12: Ideal Practice Settings Table 13: Most Important Factors When Considering Practice Opportunities Table 13a: Adjusted Physician Supply Table 14: Most Likely Demand Scenario Table 15: Current Workforce Activities in New Jersey

Figures:

Figure 1: Example of a Programmatic “Menu” to Address Physician Shortages Figure 2: Proposed Federal Workforce Solutions Figure 3: Data Sources Used By Other States Figure 4: Rural Areas of New Jersey Figure 5: Primary Care Physicians Per 100K in New Jersey Figure 6: Breakout of New Jersey’s IMG Residents/Fellows, 2008 Figure 7: Active Physician Supply Baseline Forecast: 2008-2020 Figure 8: Active Physician Supply Baseline Forecast: 2008-2020 Figure 9: Selected Assumptions of the Most Likely Demand Scenario Figure 10: Demand for Physicians in New Jersey, 2020

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Regional Definitions For purposes of this report, New Jersey’s counties were aggregated into two regions (Northern New Jersey and Southern New Jersey), as depicted in the map below.

Northern New Jersey counties: Bergen, Essex, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Passaic, Somerset, Sussex, Union, and Warren. Southern New Jersey counties: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Ocean, and Salem. Per Task Force recommendations, future endeavors will divide New Jersey into three regions: North (Bergen, Essex, Hudson, Hunterdon, Morris, Passaic, Somerset, Sussex, Union, and Warren); Central (Burlington, Mercer, Middlesex, Monmouth, and Ocean); and South (Atlantic, Camden, Cape May, Cumberland, Gloucester, and Salem).

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12

Introduction

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Introduction An adequate supply and distribution of physicians is an essential component of an effective health care system. While there is no simple ratio to determine how many physicians a nation, state, or region should have, it is possible to evaluate the adequacy of physician supply within a particular geographic area by applying supply and demand forecasting models which inform key stakeholders on future physician and health care workforce needs. Due to the length of time and great expense required for physician education and training, it is prudent to anticipate likely physician supply and demand imbalances well in advance of their potential occurrence. In the fall 2007, The New Jersey Council of Teaching Hospitals (Council), together with New Jersey’s departments of Health and Senior Services (DHSS), Banking and Insurance (DOBI), Human Services (DHS), New Jersey Hospital Association, Medical Society of New Jersey, and numerous private organizations established a Physician Workforce Policy Task Force (Task Force). The charge of the Task Force was:

▪ Undertake a needs assessment of current and future physician supply and demand, as well as distribution of physician practices across the state.

▪ Identify issues and barriers that impede the medical schools, teaching hospitals, state agencies, and “the market” at large in addressing physician shortages.

▪ Research and recommend specific strategies that will address and correct health workforce shortfalls to ensure adequate access to health care services for New Jersey citizens.

The Council hired the Center for Health Workforce Studies of the University at Albany (CHWS), who secured the modeling expertise of the Lewin Group and Altarum Institute to perform extensive review and modeling of the American Medical Association (AMA) Physician Masterfile, the New Jersey Board of Medical Examiners database, the AMA Resident database, the New Jersey Department of Labor and Workforce Development data, and the New Jersey Resident Exit Survey results. The Council embarked on parallel research of the Association of American Medical Colleges (AAMC) physician workforce data, other state health workforce activities, national physician to population ratios, and performed extensive literature searches to assess issues and proven solutions addressing physician shortages. The Task Force, through the analysis and guidance of the project consultants, and presentations by subject matter experts, spent considerable time evaluating numerous physician supply and demand models, as well as potential solutions, including expanding the advanced practice nurse (APN) and physician assistant (PA) workforce, which could address New Jersey’s impending physician shortage. BACKGROUND National Physician Shortage In January 2005, the federal Council on Graduate Medical Education (COGME) released its sixteenth report, Physician Workforce Policy Guidelines for the United States, 2000 – 2020. The report detailed forecasts of national physician supply and demand that indicated a substantial shortage of physicians by 2020. The magnitude of the shortage was estimated at 85,000 to 96,000 physicians, or between 7.5 and 8.5 percent of the likely number of physicians required to provide services for the nation’s population in 2020. With aging general and physician populations, a stagnant medical education and training effort, more than 4,000 designated primary care Health Professional Shortage Areas (HPSA), a decline in the growth of managed care payors not willing to continue supporting rising rates of physician utilization, and

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reports from a dozen medical specialties of current or impending physician shortages, it no longer made sense to think in terms of physician surpluses. The COGME’s report attempted to bring these observations together coherently. In 2008, the AAMC published “The Complexities of Physician Supply and Demand Projections through 2025” which built upon COGME’s study. Based on similar forecast models utilized by the Task Force, AAMC projected a physician shortage throughout the U.S. of up to 124,000 by 2025. One of the limitations of both the COGME and AAMC reports was their lack of attention to the regional and state specialty-specific variations embedded in its forecasts. Thus, one of the ramifications of the report was movement by concerned stakeholders in a number of states to determine how the projected national physician shortage would play out in their areas. Like New Jersey, other states have chosen to utilize nationally recognized forecasting models, such as the Health Resources and Services Administration (HRSA), to improve the evidence available for policy makers, workforce planners, and educators to make informed decisions related to medical education and training infrastructure. Using supply and demand forecasting models, states such as Arizona, California, Michigan, New York, North Carolina and Utah have studied or are examining physician workforce needs. Moreover, in the past several years, specialty-specific examinations in cardiology, endocrinology, allergy and immunology, psychiatry, neurosurgery, pediatric subspecialties, dermatology, medical genetics, radiology, geriatric medicine, and critical care have also yielded findings of current or future shortages of physicians. In 2009, signs continue to point toward worsening physician shortages and indicate that the U.S. is not producing enough doctors for its current and future needs. In recent testimony before the U.S. Senate, Richard A. Copper, M.D summarized the problem in simple terms: “Too few physicians to serve the needs of the nation; too few generalists and too few specialists.... too few physicians.”1 While states play a critical role in workforce activities, the federal government has done little in recent years to resolve current shortages or sustain a workforce for the future. This seems to be changing as Obama administration officials, who are alarmed at primary care physician shortages, are looking for ways to increase physician supply to meet the health care needs of an aging population and millions of uninsured people who could gain coverage under national health care reform legislation being championed by the president. A number of federal solutions have been discussed (Figure 2), and their likelihood of implementation should be more clear in the coming months. Figure 2. Proposed Federal Workforce Solutions

Proposed Federal Workforce Solutions

Increase Medicare payment to general practitioners Increase enrollment in medical schools and residency training programs Encourage greater use of nurse practitioners and physician assistants Expand National Health Service Corp, which deploys doctors/nurses to rural areas and poor

neighborhoods Redistribute unused GME slots to increase access to primary care and generalist physicians Promote greater flexibility for residency training programs Create Temporary Assistance for Needy Families health professions competitive grants Develop a national workforce strategy that addresses shortages and encourages training in

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New Jersey On January 11, 2006, Governor Richard Codey signed legislation that created the New Jersey Health Care Access Study Commission to study and develop specific recommendations regarding the most effective way to establish a health care system in New Jersey that provides access to health care for state residents which is affordable; is cost-efficient; provides comprehensive benefits; promotes prevention and early intervention; includes parity for mental health and other services; and eliminates disparities in access to quality health care. The Governor appointed 27 members to represent government, consumers, employers, unions, physicians, nurses, hospitals, health care associations, and health care insurance plans. The Commission’s report, published in March 2009, outlined several workforce-related recommendations: develop a coordinated health care demonstration project; create the Office for Oversight of New Jersey’s Health Care Workforce; address critical shortages of nurses and physicians; and increase Medicaid rates for health care providers. Other recommendations included: addressing the Health Care for New Jersey proposal; improving enrollment and preventing disenrollment in public health insurance programs; creating a guide to health care literacy; reducing language barriers to improve access; improving prevention and disease management; improving long-term care and end-of-life care; and improving strategies to keep coverage affordable while controlling cost (Appendix 6). In October 2006, New Jersey Governor Jon S. Corzine established the Commission on Rationalizing Health Care Resources as part of a process to evaluate and reform the state’s health plan. The Commission’s report2 presented the poor financial state of New Jersey’s hospitals and anticipated the closure of additional facilities in the short term. In early 2008, New Jersey DHSS Commissioner Heather Howard convened the Prenatal Care Task Force. Their charge was to review the adequacy of the prenatal care provider network and identify any regional or geographic barriers to care, as well as make recommendations on ways to improve access to early prenatal care and increase the number of women seeking and receiving care.3 Having found the supply of providers inadequate, the Prenatal Care Task Force recommended that the number of obstetric providers and maternal fetal medicine/ perinatal specialists be increased in order to provide timely and adequate prenatal and obstetric services throughout the state. The Commonwealth Fund report, “U.S. Variations in Child Health System Performance: A State Scorecard,” reinforced this need when it found New Jersey ranked 42nd in access to medical homes and primary care providers, and 29th in the potential to lead healthy lives, compared to other states. Research conducted by the Rutgers Center for State Health Policy (CSHP) on the availability of physician services in New Jersey between 2001 and 2006 concluded that physician supply in a number of specialties was declining.4 This research also found that the supply of physicians in New Jersey as a whole, as well as in many counties and specialties, was below the U.S. average and/or benchmarks at some point during the study period, with two counties (Cape May and Sussex) and two specialties (family medicine and hematology/oncology) below the benchmarks during the entire study period. See Appendix 5 for findings from this report. Avalere Health’s 2006 report, entitled the New Jersey Health Care Almanac, found that the number of licensed physicians practicing certain specialties in the state declined in the past five years, particularly in obstetrics/gynecology, general surgery, and neurosurgery. With respect to nursing, the state is projected to have a 25 percent nursing shortage by 2010, and similar shortfalls are expected in various allied health professions. Anecdotal evidence from interviewees also suggested that there are existing shortages for certain kinds of allied health professionals, such as radiology technicians and other clinical support staff. Lastly, also in 2006, a survey of approximately 25 percent of all registered nurses (RNs) licensed in New Jersey was conducted by the New Jersey Collaborating Center for Nursing, 16

Rutgers College of Nursing, to provide insight on the state’s nursing workforce. The study found that the nursing workforce is decreasing because of an inadequate pipeline of new nurses; an existing labor pool that is aging; a critical shortage of nursing faculty; and an alarming prevalence of job dissatisfaction and burnout. Moreover, about one third of New Jersey RNs will be retiring over the next ten years; thus, over 23,000 replacement RNs will be needed by 2016 just to maintain the current nurse supply.

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Section One New Jersey’s Current Physician Workforce

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Section One

New Jersey’s Current Physician Workforce AGGREGATE SUPPLY New Jersey has about 23,748 licensed physicians. Of those, 22,410 are post-residency, patient care physicians; 1,040 are primarily non-patient care physicians (research and administration); and 398 are residents or fellows in training (Table 2). This amounts to 253 patient care physicians per 100,000 population, which is above the state median ratio of 236.6.5 Notable characteristics of the physician supply in New Jersey include:

Nearly one-third (32 percent) are women. More than two-thirds (69 percent) are older than 45 years of age and 12 percent are

65 years of age and older. Forty percent are international medical graduates (IMGs); that is, they graduated from

a medical school outside the U.S. and Canada. Nearly three-fifths (60 percent) graduated from a medical school in the U.S. or Canada, just 14 percent graduated from one of the three6 medical schools in New Jersey; and slightly more than one-third (34 percent) completed graduate medical training in New Jersey.

New Jersey physicians are, on average, more specialized. The ratio of medical

subspecialties to population is much higher in New Jersey than in the U.S.7

In addition, New Jersey’s physician workforce is characterized by a higher than average number of active physicians nearing retirement; low medical school and physician training capacity; and low physician retention post graduation (likely due to the state’s high cost of living, high medical malpractice premiums, and low Medicaid reimbursement). Appendix 3 contains physician supply and distribution profiles for each New Jersey County showing physicians by specialty, age, gender, IMG status, and retention. DATA SOURCES AND METHODOLOGY Sources The Task Force pulled from several sources to assess current physician supply and demand in New Jersey. To calculate the current baseline number of physicians, the following data sources were used:

2008 AMA Masterfile of Physicians New Jersey Board of Medical Examiners New Jersey Department of Labor and Workforce Development

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Table 2: New Jersey Active Patient Care Physicians, 2008

Specialty Number #/100k Primary Care 8,324 94.0 Family Medicine 1,869 21.1 Internal Medicine 3,825 43.2 Pediatrics (general) 2,539 28.7 Geriatrics 91 1.0 Primary Care Related 1,973 22.3 General Surgery 620 7.0 Obstetrics and Gynecology Total 1,353 15.3 -- OB/GYN 1,276 14.4 -- GYN only 77 0.9 Internal Medicine Specialties 2,930 33.1 Cardiology 1,013 11.4 Endocrinology & Metabolism 141 1.6 Gastroenterology 438 4.9 Infectious Disease 185 2.1 Medical Oncology 113 1.3 Nephrology 224 2.5 Pulmonary Disease 322 3.6 Rheumatology 111 1.3 Other Internal Medicine 383 4.3 Surgical Specialties and Subspecialties 2,688 30.3 Neurological Surgery 115 1.3 Ophthalmology 614 6.9 Orthopedics 685 7.7 Otolaryngology 259 2.9 Plastic Surgery 234 2.6 Thoracic Surgery 141 1.6 Urology 346 3.9 Other Surgical Subspecialties 294 3.3 Facility-based Specialties 2,708 30.6 Anesthesiology 1,406 15.9 Pathology 341 3.8 Radiology 961 10.8 Psychiatrists 1,433 16.2 Psychiatry- Adult 1,302 14.7 Psychiatry- Child & Adolescent 131 1.5 Other 2,355 26.6 Allergy and Immunology 139 1.6 Dermatology 190 2.2 Emergency Medicine 780 8.8 Neurology 241 2.7 Pediatric Subspecialties 405 4.6 Physical Medicine and Rehabilitation 220 2.5 Preventive Medicine/Occ Med/Public Hlth 37 0.4 Other 343 3.9 Total 22,410 253.0 Notes: − Number of physicians per 100,000 is based on New Jersey population of 8,859,780 − See Appendix 3 for county-level physician supply data Sources: New Jersey Board of Medical Examiners; AMA Masterfile of Physicians; and New Jersey Department of Labor and Workforce Development

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While the AMA Masterfile is the most comprehensive source of data on physicians in the U.S. and is frequently the source of data analyzed in state-level physician workforce assessments, it was determined by the Task Force that this database alone did not adequately reflect the physician supply in New Jersey. To more accurately describe the current physician supply and to seed the forecasting model inputs, a list of physicians licensed to practice medicine in the state was obtained from the New Jersey Board of Medical Examiners in June 2008. The list of licensed physicians was merged with the AMA’s Masterfile of Physicians in order to attach demographic, education, and high level, practice characteristics to the licensed physicians. Based upon the practice address associated with each licensed physician, the list was “scrubbed” to better identify physicians who actually practice in New Jersey. Population, demographic, economic, and health status information about New Jersey was obtained from a variety of sources including the New Jersey Department of Labor and Workforce Development (population projections and characteristics); the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (health status indicators); the Area Resource File (health care utilization estimates); the U.S. Census Bureau (insurance status indicators); and Rutgers University economists (economic projections). It should be noted, “traditional” physician supply and demand forecasting models start with a simple assumption: the model assumes physician supply and demand are currently equal. In other words, current physician shortages are not included in the baseline mathematical calculations. This assumption concerned our Task Force, so we challenged our consultants to include current shortages into the baseline model. Identifying Current Shortages – Taking the Research to the Next Level Following the lead of other states, the Task Force sought additional information that helped show where, presently, New Jersey may be facing an insufficient supply of physicians. This included:

Findings of published reports on New Jersey’s availability of physicians services from Rutger’s CSHP, New Jersey’s Prenatal Care Task Force, and Avalere Health;

Discussion on the perceptions of Task Force members with respect to shortage

specialties and geographic mal-distribution within specialties; and Benchmarking analysis conducted by the Council using physician-to-population

ratios by specialty and from multiple sources (e.g., HRSA, AMA, insurance companies, and professional associations). See Appendix 4.

Considerations pertaining to data sources and methodology ▪ Benchmarks: County level benchmarking is useful because it sheds light on how physicians

are geographically distributed throughout a state. Mal-distribution of physician supply is an important consideration since, within a specialty, there can simultaneously be an abundance of physicians in one geographic area and a severe shortage in another. There are, however, limitations to benchmarking. First, county level data must be weighted within current patient care practice and referral patterns. For example, shortages in Ocean County may be addressed by physicians in adjacent counties, since New Jersey counties are comparatively small. In addition, the ratios used in benchmarking often reflect national

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▪ Perceptions of Task Force members: The Task Force members were frequently asked to

look beyond ratios and consider their perceptions with respect to physician shortages (e.g., recruitment difficulties, office visit wait times, etc.). In some instances (as noted throughout the report), the Task Force felt that the data did not always produce results that matched their experience of New Jersey’s physician supply, despite reputable sources and careful scrubbing.

▪ Good, but imperfect data: In true New Jersey fashion, the Task Force doggedly pursued

information that would enable them to make informed recommendations on how to address health workforce shortfalls. The group gathered and reviewed a great deal of relevant data to complete its task. However, it was apparent during the process that some desired data simply does not exist, and that New Jersey’s data collection on physician workforce issues is minimal. Thus, for future analyses, the Task Force is committed to exploring additional data sources/methodologies that more accurately profile physicians in terms of overall supply, practice characteristics, practice location, specialty, demographics, and years to retirement. Inspiration comes from other states that rely more on primary research data through customized physician surveys, often collected during the medical re-licensure process (Figure 3).

Figure 3. Data Sources Used By Other States

Georgia: The Georgia Board for Physician Workforce (GBPW), a state agency, gathers information on practicing physicians, graduating residents and medical students, and graduates of family practice programs. Physician data is obtained through a survey completed at the time of medical license renewal that yields information on physician demographics, practice location, and specialty distribution. The survey, which has a 100 percent response rate, also helps Georgia establish a ‘real’ number of practicing physicians by identifying those who are licensed, but actually retired and/or practicing in another state. In 2006, 25,724 physicians renewed a license in Georgia, but only 18,422 were actually found to be working in the state. See Appendix 8.

Massachusetts: The Massachusetts Medical Society (MMS) takes a lead role in studying physician workforce by conducting seven surveys of the following groups to evaluate the status of the state’s current workforce: practicing physicians, medical staff presidents, department chiefs in teaching hospitals, medical directors of medical groups, residency/fellowship program directors, physician offices (regarding appointment wait times), and residents (regarding patient access to care).

North Carolina: The North Carolina Health Professions Data System (HPDS) is unique in that it contains over 30 years of continuous, complete data on the state’s licensed health care professionals. Data collected, for most professions, include name, home/business address, birth year, sex, race, basic professional education information, specialty, activity status, form of employment, practice setting, total hours worked in an average week and percent time in direct patient care. In fiscal year 2007-08, costs to maintain licensure data files were just under $120,000. See Appendix 8.

Utah: The Utah Medical Education Council (UMEC), a quasi-governmental agency, studies the supply and distribution of physicians using surveys done in conjunction with medical license renewal. UMEC also collects data on other health professions, including dentists, podiatrists, physician assistants, pharmacists, registered nurses, the laboratory workforce, and radiology technicians. See Appendix 8.

▪ Rural/Urban areas: According to official U.S. Census Bureau definitions, rural areas

comprise open country and settlements with fewer than 2,500 residents. Urban areas comprise larger geographic environments that are densely settled areas, but they do not necessarily follow municipal boundaries. Most counties, whether metropolitan or non-metropolitan, contain a combination of urban and rural populations. With respect to physician workforce, rural and smaller metropolitan areas have trouble recruiting and retaining physicians since they tend to be isolated (geographically, socially, and professionally) and sometimes lacking in the quality and volume of services and amenities.8 Specialists, in particular, are unable to attain economic viability, as well as the necessary resources (e.g., hospitals, laboratories, technology, etc.), to support a specialty practice in these areas. Shortages in urban areas tend to be a function of language, insurance status,

23

and health care system design rather than total numbers of physicians. While New Jersey is considered almost entirely urban by federal definitions, like HRSA, nearly 6 percent of the state’s population reside in rural areas (Figure 4) and two thirds of the state is open space. The lack of federal HPSA9 designations clouds the reality that New Jersey does indeed have rural pockets, particularly in the south and northwestern parts of the state. The New Jersey Primary Care Association has spent considerable time in developing a rural definition that would meet the needs of New Jersey. Ten counties qualify as rural under this definition: Atlantic, Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Ocean, Salem, Sussex, and Warren. Nonetheless, to improve our understanding of physician shortages, additional data will need to be collected and analyzed in the future related to reduced patient care hours, limiting patients with specific insurance coverage, and/or limiting scope of practice both in rural and urban areas.

Figure 4: Rural Areas of New Jersey The U.S. Census Bureau defines a rural area as having fewer than 2,500 residents, and classifies as rural all territory outside urban areas. The map (at right) shows the rural (yellow) versus urban areas (green shades) of New Jersey. Source: U.S. Department of Agriculture (Economic

Census urban area (50, 000 or more)

Census urban area (10,000 – 49,999)

Census urban area (2,500 – 9,999)

Rural areas (fewer than 2,500)

PRIMARY CARE PHYSICIANS Nationally, there are signs pointing toward an uncertain future for the supply of primary care physicians. A recent survey by The Physician’s Foundation found that 78 percent of physicians believe there is a shortage of primary care doctors.10 A study published in the Journal of the American Medical Association found that only 2 percent of graduating medical students say they plan to work in primary care (internal medicine), opting instead for specialties offering better quality of life and financial rewards.11 Moreover, results from the 2009 National Resident Matching Program showed that medical students’ interest declined in family medicine (89 fewer), internal medicine (11 fewer), and pediatrics (7 fewer), as a shaky economy and the prospect of high medical school debt appear to be luring graduates into specialties other than primary care. An area of primary care that is particularly on alert is geriatric medicine. In its recent report entitled Retooling for an Aging America: Building the Health Care Workforce, the Institute of Medicine (IOM) states that the currently insufficient supply of health care professionals who care

24

for older adults will not come close to satisfying the increased demands expected in the future.12 The 7,128 physicians who are certified geriatricians in the U.S. (or one for every 2,546 older Americans) are estimated to increase to only 7,750 in 2030 (or one for every 4,254 older Americans), far short of the total predicted need of 36,000 for that year. Despite the fact that many health care providers deem work with older patients as highly satisfying, there seems to be a national shortage of geriatricians and many geriatric fellowship positions remain unfilled due to it being a specialty characterized by low compensation, unglamorous work, a lack of mentors, and various financial disincentives. The fill rate of geriatric medicine training positions was only 54%.13 In New Jersey, there are approximately 8,324 primary care physicians14 providing clinical care (out of a total of 8,698 who are licensed). This ratio equals 94.0 primary care physicians providing clinical care per 100,000 people. One would initially assume that primary care physician supply is adequate since New Jersey’s ratio is above the national average (88.1)15. However, statewide totals ignore mal-distribution of primary care physicians in specific regions and/or counties. A closer look at the individual primary care specialties reveals insufficiencies (Figure 5).

Figure 5: Primary Care Physicians Per 100K In New Jersey

Figure 5 illustrates how the primary care physicians per 100,000 people compared, by county, to the national average ratio (88.1). The ratios in New Jersey’s 21 counties range from a low of 57.8 primary care physicians per 100,000 people (Sussex County) to a high of 119.6 per 100,000 people (Mercer County). Twelve counties fall below the national average, including all but one county (Camden County). This suggests poor distribution of primary care providers in the state, particularly in the south, rather than a total supply problem. The 2008 New Jersey Resident Exit Survey also hints at potential deficiencies in the primary care workforce pipeline. The respondents choosing primary care (both residents entering patient care/clinical care and those continuing training for sub-specialization) were below the average number of respondents, compared to previous annual surveys. Of the residents entering patient care, those in primary care specialties were more likely to practice in suburban and inner city areas (42 and 25 percent, respectively) than in small cities or rural towns (14 and 6 percent, respectively). They were also more likely to leave the state altogether (60 percent) than the non-primary care residents (45 percent).

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In particular, the Task Force sensed that the supply of family physicians in New Jersey was insufficient, and a number of signs point toward an inadequate supply:

The New Jersey Academy of Family Physicians believes that family medicine physicians “remain undervalued and under fire” and that there is a shortage of family physicians and primary care in the state.16

A Rutgers CSHP study found that the state’s family practice supply fell below national averages or published benchmarks in all study years. 17

The American Academy of Family Physicians (AAFP) predicted a shortage of family medicine physicians and suggested a family physician-to-population ratio of 41.6 in order to meet the nation’s primary care needs (based on the assumption that family physicians will make up half of all generalists). For New Jersey, this means that 2,680 family physicians would be needed in 2006 and 3,551 in 2020.18

A Rutgers CSHP analysis reported a 12 percent drop in family medicine residents in New Jersey over the past 12 years (230 to 203), compared to a 2 percent increase nationally.19

Benchmarking completed by the Council (Appendix 4) also confirmed current supply deficiencies in family medicine. There are 1,869 family physicians providing patient care in New Jersey (or 21.1 per 100,000 population), which is well below national averages and recommendations. Applying a ratio of 26.5 (i.e., average of five ratios for family medicine physicians) reveals a statewide deficiency with 13 counties below the benchmark, including almost every county in Northern New Jersey (Table 3). Applying the 41.6 ratio recommended by AAFP puts all but one county (Hunterdon) below the benchmark.

TABLE 3: Unmet Need of Family Medicine Physicians in New Jersey

(Amounts represent patient care physicians only)

CURRENT 2020 County # #/100k Average

Ratio Unmet Need

(# physicians) AAFP

Ratio Unmet Need

(# physicians) Bergen 134 14.7 26.5 -107.1 41.6 -244.2 Essex 108 13.4 26.5 -105.1 41.6 -226.3 Hudson 102 16.8 26.5 -59.6 41.6 -151.5 Hunterdon 88 65.6 26.5 52.4 41.6 32.2 Mercer 79 21.3 26.5 -19.4 41.6 -75.4 Middlesex 163 20.4 26.5 -49.1 41.6 -169.6 Monmouth 99 15.3 26.5 -72.8 41.6 -170.5 Morris 100 20.0 26.5 -32.8 41.6 -108.3 Passaic 76 15.0 26.5 -58.4 41.6 -134.9 Somerset 100 30.7 26.5 13.6 41.6 -35.5 Sussex 26 16.5 26.5 -15.8 41.6 -39.5 Union 70 13.0 26.5 -72.8 41.6 -154.0 Warren 46 40.8 26.5 16.1 41.6 -0.9 Northern NJ 1,191 18.6 26.5 -510.8 41.6 -1,478.5 Atlantic 53 19.2 26.5 -20.1 41.6 -61.7 Burlington 162 35.2 26.5 39.8 41.6 -29.7 Camden 215 41.0 26.5 76.0 41.6 -3.0 Cape May 36 36.3 26.5 9.7 41.6 -5.3 Cumberland 35 22.7 26.5 -5.8 41.6 -29.0 Gloucester 84 29.7 26.5 8.9 41.6 -33.8 Ocean 70 12.1 26.5 -83.4 41.6 -170.6 Salem 22 32.7 26.5 4.2 41.6 -6.0 Southern NJ 678 27.8 26.5 30.2 41.6 -338.2 NEW JERSEY 1,869 21.1 26.5 -480.6 41.6 -1,816.7

Based on U.S. trends, New Jersey is one of many states needing more geriatricians to meet the demands of its expanding older population. At present, the entire state has about 91 geriatricians, or a density of 8 per 100,000 older adults. Projections conducted by the American 26

Geriatric Society (AGS) show that New Jersey’s current geriatrician shortfall is 178 physicians. New Jersey will need to train an additional 536 geriatricians by 2030 to meet the projected future demand of our senior population.20 Using ASG recommended ratios, the Council benchmarking indicated an insufficient supply of geriatricians in every New Jersey county (Appendix 4). The specialties of general surgery and obstetrics/gynecology (OB/GYN) were included in discussions on New Jersey’s primary care workforce since both groups see a variety of medical conditions and increasingly perform more ‘traditional’ primary care functions (e.g., first contact, care coordination, etc.), especially in rural and underserved populations. Across the state, benchmarking completed by the Council showed current surpluses for OB/GYN and general surgery, with the only exception being a shortage of surgeons in Southern New Jersey (Appendix 4). It should be noted that the Task Force questioned results pertaining to OB/GYN physicians. The consensus was that the supply of OB/GYN physicians performing deliveries, a group challenged by rising malpractice premiums, is insufficient and that further analysis must be completed to better understand gynecology and obstetrics as separate specialties. Possibly, by combining these physicians, the real supply of obstetricians is being overstated. Lastly, it will be critical for states that are looking to adopt universal health care insurance coverage, like New Jersey, to ensure an adequate and well-distributed primary care workforce. Massachusetts’ implementation of universal coverage legislation in 2006 led to a primary health care bottleneck when there were not enough health professionals serving in the right places to meet the increased needs of the state’s newly insured population. Community health centers, which target the health care needs of the medically underserved, are playing a critical role in caring for the newly-insured patients while simultaneously serving as the primary care safety net for uninsured residents. Between 2005 and 2007, the total number of patients at health centers within Massachusetts rose by 50,000. New Jersey has 19 federally qualified health centers (FQHCs) with 99 satellite sites, which are the major provider of comprehensive community-based primary health care. In 2008, they served 366,785 persons and provided over 1,133,366 medical and dental visits.21 SPECIALIST PHYSICIANS While primary care is often the focus of physician workforce debates, evidence at the nationwide level shows that some specialty physicians also may be facing a crisis.

Studies by medical specialty organizations, state medical societies, and state workforce task forces have documented a need in many specialties, including anesthesiology, cardiology, emergency medicine, gastroenterology, nephrology, pediatric subspecialties, pulmonary, hematology/oncology, radiology, and rheumatology.22

In a national survey of medical school deans and state medical societies, shortages were most frequently cited in anesthesiology and radiology (Table 4).

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Table 4. Perceived Specialty Shortages and Surpluses of Physicians

JAMA, December 10, 2003, Vol. 290, p2993. Copyright ©2003, American Medical Association. All rights reserved.

A 2002 NACHRI survey found that a shortage of pediatric subspecialists may become the top strategic and operational issues facing children’s hospitals. Endocrinology, paleontology, and neurology had the highest vacancy rates while neurology and gastroenterology presented the greatest recruiting challenge.23

According to the American Academy of Pediatrics, the most pressing issues in pediatrics are the geographic mal-distribution of physicians, mainly in rural and urban underserved areas, and supply gaps in most of the pediatric subspecialties.24

In New Jersey, physicians tend to be more specialized, and the ratio of medical subspecialties is notably higher in the state than nationally. Contributing factors may include:

High population, density crowded states and metropolitan areas tend to have more specialists and fewer primary care physicians.

High per capita income specialists tend to congregate in high income regions where citizens can afford more specialist visits, mainly for elective procedures. On average, a 1 percent increase in per capita income leads to a .66 percent increase in demand for specialty services.

A pipeline (i.e., medical education and teaching hospitals) geared toward specialty care.

High public education expenditures per pupil- there is speculation that educated people may gravitate towards specialists (and specialist careers). In New Jersey, expenditure per pupil was the second highest in the US at $14,630 in 2005-06.25

Similar to primary care, a collective look at New Jersey’s specialist physicians can be deceiving since it ignores shortages that persist in specific geographies. Signs point toward shortages in some specialties. In addition to family practice, Rutgers CSHP found that New Jersey physician supply between 2001 to 2006 fell below Weiner26 benchmarks in the specialties of hematology/oncology, pediatric subspecialties, and emergency medicine and fell below U.S. supply (i.e., physician ratios per 100,000 population) in hematology/oncology, general surgery, neurological surgery, orthopedics, otolaryngology, thoracic surgery, pathology, radiology,

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diagnostic radiology, vascular surgery, nuclear medicine, psychiatry, emergency medicine, and general preventive (Appendix 5). Benchmarking conducted by the Council, using 2008 physician data, found statewide deficiencies in dermatology, emergency medicine, hematology/oncology (South only), and neurology (South only), as well as in 73 percent of pediatric subspecialties (Appendix 4). While the supply of psychiatrists in New Jersey appeared sufficient, the Task Force’s perception was that it is difficult to get appointments with these physicians and that more investigation is needed to confirm whether insurance issues or poor geographic distribution is fueling this problem. Table 5 shows the widespread shortages in the pediatric subspecialties. Statewide, physician supply was below benchmark levels in 19 out of 26 subspecialties. Southern New Jersey was most heavily impacted by deficits, showing shortages in areas where the rest of the state appeared to have sufficient supply (e.g., anesthesiology, child neurology, and orthopedics). Ben In addition, the New Jersey Council of Children’s Hospitals determined the lack of pediatric subspecialists is a critical state issue and has identified the following pediatric subspecialties as having the most critical shortages based on wait times for appointments: child/adolescent psychiatry (Medicaid), child neurology, behavioral psychology, developmental pediatrics, neurosurgery, orthopedic surgery, otolaryngology, diagnostic radiology, cardiology (South only), endocrinology (North only), gastroenterology (North only), general surgery, urology (Medicaid), and dentistry (Medicaid).

Table 5. Pediatric Sub specialist Shortages in New Jersey, 2008

Pediatric Subspecialties North NJ South NJ Adolescent Medicine Allergy Anesthesiology Cardiology Child Neurology Critical Care Medicine Developmental Behavioral Emergency Medicine Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Internal Medicine (Pediatrics) Nephrology Orthopedics Pulmonology Radiology Rheumatology Sports Medicine

Results are based on benchmarking analysis done by New Jersey Council of Teaching Hospitals The following specialties did not show shortages: child and adolescent psychiatry, neonatal-

perinatal care, ophthalmology, otolaryngology, pathology, surgery, and urology

INTERNATIONAL MEDICAL GRADUATES (IMGs) IMGs provide a steady and significant supply for the U.S. physician workforce, representing a quarter of all physicians. Compared to U.S. medical graduates (USMGs), IMGs tend to be older (by about 3 years), have a higher number of years since graduation from medical school (by about 5 years) and have a practice specialty of internal medicine.27 IMG contributions span

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direct patient care as well as academic medicine and research, and are unsurpassed in two distinct areas:

▪ IMGs are more willing to practice in underserved areas through J-1 visa waivers ▪ IMGs are more likely to possess a greater sensitivity to cross-cultural issues

The primary IMG specialties include: anesthesiology (29 percent), internal medicine (36 percent), psychiatry (31 percent), pediatrics (28 percent), general surgery (20 percent), radiology (19 percent), family medicine (18 percent), and OB-GYN (18 percent).28 In terms of practice location, IMGs tend to locate in the same state as where they completed their GME training, practice where IMG networks already exist, and locate in communities with higher proportions of the people of the same ethnicity.29 In New Jersey, IMGs are a large component of the physician workforce. AAMC reported that nearly 40 percent of licensed, active physicians in New Jersey are IMGs, placing it first among the 50 states (Table 6). Moreover, 59 percent of the residents/fellows are IMGs (see next section), with the highest concentration of IMG residents/fellows located in psychiatry (77%) and primary care (73%).30

TABLE 6: Percentage of Active Physicians Who are IMGs (Northeast), 2007

Rank State % Active Physicians

1 New Jersey 39.9% 2 New York 39.5% 7 Delaware 27.4% 8 Maryland 26.9% 9 Connecticut 26.8% 16 Pennsylvania 22.0%

SOURCE: 2007 State Physician Workforce Data Book (AAMC)

Notably, a large and growing component of IMG residents/fellows (59 percent) are either a U.S. citizen or permanent resident (Figure 6), most often enrolling in Caribbean medical schools. These medical students often return to the U.S. for clerkships in years 3 and 4. New Jersey provides 290 clerkship positions for these Caribbean schools, with 60 percent of the positions currently being utilized.

Figure 6: Breakout of New Jersey's IMG Residents/Fellows, 2008

US-Born Citizen12%

Naturalized/Permanent Resident

22%

Temporary Visa13%

USMGs41%

IMGs59%

Unknown11%

NOTE: Sum of parts do not equal total IMGs due to rounding.

Many IMGs with temporary visas use the Conrad State 30 Program to establish a medical practice in the U.S. This program facilitates foreign physicians on J-1 visas to avoid a requirement that they leave the nation for two years before they apply to return, provided they agree to practice in medically underserved communities for three years. In 2007, New Jersey’s

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Conrad State 30 Program placed five J-1 doctors (out of 30 allotted), mostly in children’s hospitals. Despite numerous contributions to the physician workforce, it is increasingly difficult for immigrant physicians to practice medicine in the U.S. due to:

Difficult entry requirements, especially after terrorist attacks on September 11, 2001; Language barriers; Drastically different professional and doctor-patient relationships; and Steep learning curves (e.g., hundreds of new brand names and laboratory values).

There is also belief that IMG dependency discourages investments in cultivating future aspiring U.S. physicians and raises moral issues. A key moral question: Is the U.S. decreasing the physician workforce supply within non U.S. countries, thus harming the availability of physicians to provide necessary health care for their country of origin’s population? This debate, along with the sometimes poorly documented retention rates of IMGs in shortage areas, has forced states to question their future reliance on IMGs to boost physician supply.

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Section Two New Jersey’s Medical Education Pipeline

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Section Two New Jersey’s Medical Education Pipeline For all states, the most convenient and logical source for future physicians is those who attended in-state medical schools or those who obtained graduate medical training in their state.31 UNDERGRADUATE MEDICAL EDUCATION (UME) New Jersey has 3 medical schools (2 allopathic and 1 osteopathic) and one school (allopathic) under development, Touro University College of Medicine, due to open in the fall of 2010. During the 2006/07 academic year, 1,762 medical students were enrolled in these three schools.32 Compared to other parts of the country, New Jersey lags behind in medical school capacity. A CHWS report completed for the Task Force profiling New Jersey’s medical education and training found:

Low Enrollment Levels. Despite a 1.4 percent increase in enrollment over the last decade, New Jersey has far fewer medical students compared to other states (Table 7).

Falling Graduation Rates. New Jersey experienced a 6 percent increase in medical

school graduates, amounting to 22 additional annual graduates in 2006/07 compared to 1995/96. However, taking into account population changes, this was a 3.4 percent decline, moving from 4.8 medical graduates per 100,000 to 4.6 (Table 7).

Low Matriculation. Of New Jersey residents applying to U.S. medical schools in

2007, 20.5 percent matriculated in-state, 23.9 percent went out-of-state, and 55.6 percent did not matriculate. Comparatively, 30.6 percent of New York and 27.3 percent of Pennsylvania residents stayed in-state.33

TABLE 7: Medical Education Comparison, 2006/07

NJ Mid-Atlantic

(NY and PA)

Northeast (CT, ME, MA, NH, RI, & VT)

US

Enrolled medical students per 100K 20.2 40.5 38.8 27.8 Medical graduates per 100K 4.6 9.8 9.4 6.5 Residents/Fellows per 100K 30.2 62.3 61.8 35.0

Source: Center for Health Workforce Studies

GRADUATE MEDICAL EDUCATION (GME) In 2007, there were about 2,636 resident and fellow training positions in New Jersey. Despite some growth (6 percent) in the number of physicians in graduate medical positions in the state over the past decade, New Jersey continues to lag behind in its capacity to train physicians relative to its neighbors and the nation as a whole. The national average for graduate medical training capacity is 35 training positions per 100,000 people. In New Jersey, the capacity in 2007 was 30 training positions per 100,000 people (Table 7). Further, compared to neighboring

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states in the Northeastern US, New Jersey lags even further behind their average capacity of 62 training positions per 100,000 people (Table 7). Table 8 shows the changes in the number of residents/fellows training in New Jersey between 1995/96 and 2006/07. Comparing this data to the Task Force’s list of ‘targeted’ shortage specialties (see Section Three), there was growth within the state in many of the areas that currently have insufficient supply (e.g., emergency medicine, general surgery, obstetrics/gynecology, neurology, and pediatric subspecialties). The 17 percent growth in pediatric subspecialists, however, was marked by only 2 physicians. Unfortunately, the GME pipeline does not look as favorable for family medicine and psychiatry, where trainees fell by 12 percent and 8 percent, respectively, and both were below the national percentage changes for the same period.

TABLE 8: Number of New Jersey Residents/Fellows by Specialty, 1995/96 and 2006/07

1995/96 2006/07 Specialties in red may currently be in short supply

State Change

National Change

Family Medicine 230 203 -12% 2% Internal Medicine 876 869 -1% 5% Pediatrics 260 277 7% 8% Geriatrics* 7 8 14% -13% Obstetrics and Gynecology 137 158 15% -5%

Primary Care Specialties (or those largely providing primary care functions)

General Surgery 194 209 8% -7% Anesthesiology 88 89 1% 6% Emergency Medicine 15 87 480% 56% Pathology - Anatomic and Clinical 41 40 -2% -17%

Hospital-based Specialties

Radiology - Diagnostic 91 100 10% 7%

Colon and Rectal Surgery 3 3 0% 34% Neurological Surgery 0 9 4% Ophthalmology 25 15 -40% -24% Orthopedic Surgery 53 67 26% 11% Otolaryngology 8 10 25% 7% Plastic Surgery 6 6 0% 32% Thoracic Surgery 11 2 -82% -18% Urology 14 16 14% -9%

Surgical Specialties and Subspecialties

Surgical Subspecialties 7 12 71% 39%

Internal Medicine Subspecialties 148 185 25% 20% Pediatric Subspecialties 12 14 17% 75% Combined Specialties 37 23 -38% 37%

Allergy and Immunology 4 4 0% 8% Dermatology 5 12 140% 26% Neurology 19 30 58% 4% Physical Medicine and Rehabilitation 41 38 -7% 3% Preventive Medicine 8 3 -63% -34% Psychiatry 105 97 -8% -6% Transitional Year 43 17 -60% -17%

Other Specialties and Subspecialties

All Others 26 41 58% 41% Total 2,507 2,636 5% 7%

Sources: State-level Data for Accredited Graduate Medical Education Programs in the U.S., 1995/96 and 2006/07. AMA.

*Geriatrics data are for the years 1998 and 2008; source is the state-level data for accredited GME programs in U.S. AMA

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Table 9 illustrates the pool from which residents/fellows are drawn which is also an important workforce consideration. Research from the CHWS, completed for the Task Force, found that 32 percent of the residents/fellows training in New Jersey come from U.S. medical schools, with only 12 percent graduating from an in-state school. As stated earlier, the majority of residents/fellows (59 percent) come from international schools. With respect to the specialty groups, the surgical specialties and subspecialties relied most heavily on physicians from medical schools outside the state, with more than half of the residents/fellows in those programs having attended a medical school outside New Jersey. The exception is urology that had 56 percent in-state physicians. The hospital-based specialties consistently had the greatest concentration of residents/fellows from New Jersey medical schools. The primary care specialties were most reliant on IMGs with 74 percent of residents/fellows having attended a medical school outside the U.S. and Canada.

TABLE 9: Origins of Physicians Training in New Jersey, 2006/07

Specialties Specialties in red may currently be in short supply

In-State*

Out-of-State*

International

Canada

Osteopathic

Family Medicine 9% 8% 73% 0% 9%

Internal Medicine 6% 9% 80% 0% 6%

Pediatrics 8% 12% 64% 0% 16%

Primary Care Specialties

Geriatrics 0% 0% 100% 0% 0%

Obstetrics and Gynecology 9% 15% 64% 0% 12% Primary Care-Related Specialties General Surgery 16% 44% 37% 0% 2%

Anesthesiology 18% 25% 45% 0% 12%

Emergency Medicine 22% 49% 10% 0% 18%

Pathology - Anatomic and Clinical 10% 3% 88% 0% 0%

Hospital-based Specialties

Radiology - Diagnostic 31% 58% 7% 0% 4%

Colon and Rectal Surgery 0% 100% 0% 0% 0%

Neurological Surgery 11% 89% 0% 0% 0%

Ophthalmology 40% 47% 13% 0% 0%

Orthopedic Surgery 22% 70% 6% 0% 1%

Otolaryngology 10% 90% 0% 0% 0%

Plastic Surgery 33% 50% 17% 0% 0%

Thoracic Surgery 0% 100% 0% 0% 0%

Urology 56% 38% 6% 0% 0%

Surgical Specialties and Subspecialties

Surgical Subspecialties 0% 42% 42% 8% 8% Internal Medicine Subspecialties 15% 16% 56% 1% 12% Pediatric Subspecialties 0% 7% 79% 7% 7% Combined Specialties 26% 17% 39% 4% 13%

Allergy and Immunology 0% 50% 50% 0% 0%

Dermatology 50% 42% 8% 2% 0%

Neurology 3% 3% 83% 0% 10% Physical Medicine and Rehabilitation 42% 39% 0% 0% 18%

Preventive Medicine 0% 33% 67% 0% 0%

Other Specialties and Subspecialties

Psychiatry 15% 7% 64% 0% 13% Total 12% 20% 59% 0% 9%

*In-State and Out-of-State refer to allopathic schools only. Sources: State-level Data for Accredited GME programs in the U.S., 2006/07. AMA 36

RETENTION Case studies presented by Jefferson Medical College in Pennsylvania and the Georgia Board for Physician Workforce, along with numerous publications, suggest that birth place and growing up in the same state are strong predictors of a student staying in-state to establish clinical practice. These predictors become increasingly stronger if the person stays in-state for medical school and then for residency. In rural physician studies, which are largely applicable to primary care, the literature has repeatedly and consistently documented that rural-raised individuals are more likely to return to their “rural roots” and establish practices in underserved, rural areas. Additionally, pairing rural-raised individuals with mentoring in the value of family medicine has a cumulative effect.34 Students enrolled in Jefferson’s Physician Shortage Area Program, who are selected for their intent on becoming a family physician, as well as for their background in a small town or rural area, are eight times more likely than their peers to become rural family physicians, two times more likely to specialize in internal medicine/pediatrics, and twenty percent more likely to become rural non-primary care physicians. Annually, between 800 and 850 physicians complete GME in New Jersey. Of these physicians, nearly 60 percent leave the state. Those physicians seeking additional training after completing a residency or fellowship training program in New Jersey are more likely to leave the state than those entering patient care or clinical practice upon completion of their training. According to a 2009 resident exit survey conducted by the Council, only 29 percent of respondents had future plans to stay in New Jersey after training while 62 percent were leaving the state or country, and 9 percent did not know their next location. Of the resident/fellows headed for additional training/fellowship in another state, only 12 percent responded that they planned to return to New Jersey later to establish a practice. For the residents/fellows entering clinical practice outside New Jersey (65 percent), the key factors in leaving the state were proximity to family, better job opportunities in other states, and the sense that better salary/compensation existed outside New Jersey. Lastly, the survey showed that residents and fellows who grew up in New Jersey and trained in New Jersey were by far the most likely to stay in New Jersey.

Fewer than half of new physicians are staying in New Jersey after completing training

New Jersey natives who attended an in-state medical school are the most likely to report plans to practice in New Jersey after completing GME training

Proximity to family and better job/practice opportunities were the top two reasons citied by new physicians for planning to practice outside New Jersey

2009 Resident Exit Survey (NJCTH)

Table 10 illustrates how retention rates in New Jersey, as reported by the AAMC, compare to the Middle Atlantic division and the U.S. There appears to be a link between the amount of education/training a physician receives in a state and the likelihood of him/her staying to practice in a state. Thus, recruiting and retaining state residents into New Jersey’s medical education pipeline looks to be a worthwhile investment.

TABLE 10: Comparison of Retention Rates in Surrounding States

NJ NY PA US Benchmark Physicians who graduated UME in the state and are active in the state 35.3% 36.5% 34.8% 38.8% 62.4% (CA) Physicians who graduated GME in the state and are active in the state 46.9% 46.4% 42.1% 47.2% 69.8% (AK) Physicians who graduated UME and GME in the state and are active in the state 64.4% 58.2% 58.6% 66.0% 83.5% (HI)

SOURCE: 2007 State Physician Workforce Data Book, AAMC.

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In New Jersey, low numbers of residents/fellows in the shortage specialties (e.g., family medicine, obstetrics and gynecology, and pediatric subspecialties) graduated from in-state medical schools (Table 9). Workforce retention and recruitment strategies should aim to reverse this trend. Other Factors impacting Physician Supply Beyond current and future supply/demand scenarios, the Task Force considered other factors known to influence physician decision-making regarding specialization (i.e., primary care versus specialty) practice, the pursuit of further training post-residency, or practice location. Current physicians in training have a very different mindset compared to physicians who graduated 20 years ago. The friendliness of the practice environment as well as the balance between their professional career and personal lives greatly impact decision-making. Unfortunately, New Jersey is considered to have a hostile practice environment due to several key factors, including; under-compensation, over-regulations, unwillingness to address medical malpractice crisis in a more substantive way and few opportunities for practice in large single specialty or multi-specialty group practices. Lifestyle Choices In its 2008 Survey of Final Year Medical Residents, Merritt Hawkins & Associates found that geographic location/lifestyle was the most important consideration in identifying practice opportunities (Table 11). Other studies35,36 have also found lifestyle to be a key factor in the career decisions of medical students, who are increasingly drawn toward specialties with “controllable” lifestyles. A controllable lifestyle, defined as having more personal time and greater control of hours spent on professional duties, seems to be drawing medical students towards residency programs in radiology and anesthesiology, and away from programs in general surgery, family practice, and internal medicine. Undoubtedly, this trend will alter the composition of the physician workforce, leading to an increased supply of physicians in specialties with controllable lifestyles and a decreased supply in uncontrollable specialties.

Table 11: Controllable vs. Uncontrollable Lifestyle Specialties

Specialties with perceived “controllable” lifestyle

Specialties with perceived “uncontrollable” lifestyle

Anesthesiology Dermatology

Emergency Medicine Neurology

Ophthalmology Otolaryngology

Pathology Psychiatry Radiology

Family Practice Internal Medicine

Obstetrics/Gynecology Orthopedic Surgery

Pediatrics Surgery (general)

Urology

Medical Malpractice Of respondents who indicated in the Council’s 2009 resident exit survey that they were going to practice outside New Jersey, not one indicated the cost of malpractice insurance as a main reason for leaving the state. Nonetheless, New Jersey is one of several states that is listed as having a medical malpractice liability crisis by the AMA, whose main determining factor is the degree to which patients are losing access to care followed by the affordability/availability of professional liability insurance; severity of jury awards and settlements; and a state’s legislative, legal, and judicial climates. A variety of tort reforms have been tested by states, including limits to non-economic damages, expert witness standards, apology statements, greater insurance

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company accountability, and litigation alternatives. The malpractice crises have caused physicians to reduce their scope of practice, leave states, or choose early retirement; and could clearly limit physician supply in the hardest hit specialties (e.g., obstetrics and gynecology, surgery, orthopedic surgery, radiology, neurology, and emergency medicine). Alternatively, while the impact of a friendlier malpractice climate is hotly debated, historical trends demonstrate that states passing laws to protect physicians from large malpractice awards are better able to attract and retain physicians.

In 2008, New Jersey’s Medical Malpractice Liability Insurance Premium Assistance Fund provided more than $16 million in financial aid to nearly 1,200 obstetricians, neurosurgeons, and radiologists37. Practice Setting According to Merritt Hawkins & Associates, physician recruits seem to be most interested in practicing in an employed setting with either a medical group or a hospital (Table 12). Only 1 percent of residents are open to solo practice, which is down from 8 percent in 2001. Similar results were found in another study38 that indicated residents seek settings where they can concentrate on their specialty area of practice, like hospitals or single specialty practices. Likewise, the Council’s 2009 Resident Exit Survey indicated that 80 percent of respondents going into patient care were headed into a group practice or hospital setting, and a majority (65 percent) were going to be employees in their upcoming practice, rather than partners and/or owners. In terms of recruitment and retention, New Jersey’s preponderance of one and two physician practices is a disincentive for most new physicians.

Table 12: Ideal Practice Settings

Ideal Practice Settings

Partnership 24% Single Specialty Group 23% Hospital Employee 22% Multi-Specialty Group 16% Outpatient Clinic 8% Association 4% Unsure 1% Solo 1% HMO 1% Locum Tenens 0%

Source: 2008 Survey of Final Year Medical Residents. Merritt Hawkins & Associates.

Student Debt After geographic/lifestyle considerations, a strong competitive financial package and loan forgiveness were the top factors that medical residents looked for in a practice according to a national survey (Table 13). Increased debt seems to correlate with specialty choice, having a negative impact on medical residents choosing less lucrative primary care specialties like family practice. The average graduating medical school debt has risen faster than the consumer price index for the past 20 years, and seems to be increasing more rapidly than physician incomes. According to the AAMC, the median debt of a public medical school graduate was $120,000 in 2006, a 6.9 percent increase over the previous year. The median debt for private school graduates was $160,000 (or a 5.9 percent increase). Moreover, the percentage of students in

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debt at graduation has grown to 86 percent for public medical school graduates and 85 percent for private school graduates39. Projections for the debt of both public and private medical school graduates are about $750,000 by 2033. According to AAMC, the 2008/09 tuition for New Jersey medical schools is $25,218 and $39,461 for residents and nonresidents, respectively. This is a 9 percent increase from the previous year and a 63 percent increase from ten years ago. However, despite rising tuition, the Council’s 2009 resident exit survey showed that about 58 percent of New Jersey’s residents and fellows have a current educational debt level of less than $100,000, with 37 percent having no debt at all. Moreover, an overwhelming majority (91%) of respondents indicated that they will not be participating in a loan forgiveness/repayment program.

Table 13: Most Important Factors When Considering Practice Opportunities

Most Important Factors When Considering Practice Opportunities

Most Important Geographic location/lifestyle 57% Good financial package 46% Educational loan forgiveness 42% Low malpractice area 33% Proximity to family 30% Adequate call/coverage/personal time 28% Good medical facilities/equipment 23% Specialty support 17%

Source: 2008 Survey of Final Year Medical Residents. Merritt Hawkins & Associates.

Reimbursement Rates

Physician reimbursement rates vary widely by specialty and state, and are based on a number of factors such as geography, work requirements, practice expense, and malpractice expense. As one would expect, payments from government reimbursement programs factor into whether a state is considered to have a practice environment that recognizes the value of physicians and supports, through these state driven reimbursement rates, the success of a medical practice. A review of 2007 Medicare data showed that New Jersey received about $10,567 per person served by Medicare, which was well above the U.S. amount of $8,921 per person. With respect to Medicaid, New Jersey does not fare well. Average physician fees in 2008 were only 58 percent of the national average, the lowest of all states, and were only 37 percent of Medicare payments. In primary care and obstetrics, New Jersey’s average Medicaid fees were only 69 percent and 37 percent of the national average, respectfully. Lastly, a GAO study40 that looked at physician prices paid by the Federal Employees Health Benefit Program ranked all of New Jersey’s metropolitan areas in the lowest quartile. The impact of low reimbursement rates on physician workforce is unclear, but it certainly could be an obstacle to physician recruitment and retention.

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Section Three A Summary of New Jersey’s Current Physician Supply

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Section Three A Summary of New Jersey’s Current Physician Su