1. Rhode Island: A Brief State of the State D Roxanne Richards May 24, 2012

2. Today’s Objectives  Rhode Island Characteristics  Demographics  Economy  Workforce characteristics  Current Primary Care Workforce  Training milieu  Primary Care Infrastructure  Mapping Need  Key Disparities  Trends  In the News  Recent Legislative Actions and Agency Programs

3. Rhode Island Characteristics

4. State of Rhode Island and Providence Plantations Rhode Island in United States (zoom) (extra close) (US48).svg from Wikimedia Commons 1

5. Metropolitan vs. Non-metropolitan Areas “The Health of Rhode Island Non-Metropolitan Communities”, Office of Primary Care and Rural Health, November 2011.

6. Ethnicity Composition Census 2010 Quick Facts: Rhode Island

7. Metropolitan vs. Non-metropolitan “The Health of Rhode Island Non-Metropolitan Communities”, Office of Primary Care and Rural Health, November 2011; Fact Finder 2, US Census Bureau

8. Mapping Poverty: Population at or below 100% FPL UDS Mapper, http://www.udsmapper.org, accessed May 23, 2012

9. Insurance Rates and Healthcare Expenditures  Insured by public plan: 21% (US average 20%) 4  Total Uninsured: 199,100 (13%) (US average 18%) 4  Uninsured under 100% FPL: 41% (US average 41%)  Uninsured 100-138% FPL: 10% (US average 13%)  Uninsured 139-250% FPL: 24% (US average 24%)  Uninsured 251-399% FPL: 12% (US average 13%)  Uninsured 400%+ FPL: 13% (US average 10%)  HC expenditures per capita (2009): $8309 (US average $6815) 4

10. Insurance Rates and Healthcare Expenditures Kaiser Family Foundation, StateHealthFacts.org

11. Insurance Rates: Compared to Neighboring States Fact Finder 2, US Census Bureau

12. Economy and Politics  Based in service industries 7  Healthcare (1 st )  Tourism (2 nd )  Manufacturing (3 rd )  Recent Tax Reform (June 2010) 2  Make RI more business-friendly  Reliably Democratic state 2  Has voted for Democratic nominees for president in all but 7 elections since 1908

13. Health Reform: Where is RI at in the process?  HIE established  State is active purchaser  PCIP in place  Currently 149 enrollees  Medicaid Expansion Estimates (KFF.org):  % change in enrollment: + 20.0% (US average +27.4%)  % change in STATE spending: +0.7% (US average +1.4%)  % change in FEDERAL spending: 14.6% (US average +22.1%) Kaiser Family Foundation, StateHealthFacts.org

14. Workforce Characteristics

15. Current PC Provider Supply: Total Active Physicians per Population AAMC Physician Workforce State Profiles

16. Current PC Provider Supply: Active PC Physicians per Population AAMC Physician Workforce State Profiles

17. Current Nurse Practitioner Supply “Total Nurse Practitioners, 2011”, Kaiser Family Foundation

18. Current Physician Assistant Supply “Total Physician Assistants, 2011”, Kaiser Family Foundation,

19. Distribution of All RI Physicians: RI AHEC Primary Care Mapping Project (2008) RI AHEC Primary Care Mapping Project (2008)

20. Distribution of PC Physicians: RI AHEC Primary Care Mapping Project (2008) RI AHEC Primary Care Mapping Project (2008)

21. Physician Density by Municipality: RI AHEC Primary Care Mapping Project (2008) RI AHEC Primary Care Mapping Project (2008)

22. Physician Training: UME in New England Region 26  RI: one private (Brown University, Alpert Medical School)  MA: one public, three private  CT: one public, one private  NH: one private  VT: one public  ME: one private  NY: five public, eight private Tuition and Student Fees Reports, AAMC, 2010

23. Physician Retention: UME AAMC Physician Workforce State Profiles

24. Physician Training: GME in New England Region ACGME data from AMA-MF

25. Physician Retention: GME AAMC Physician Workforce State Profiles

26. Migration of Physicians into RI: Most Common GME States, All Physicians ACGME data from AMA-MF

27. Migration of Physicians into RI: Most Common GME States, PC Physicians ACGME data from AMA-MF

28. Primary Care Infrastructure

29. Mapping Need in RI: HPSA’s UDS Mapper, udsmapper.org

30. Mapping Need in RI: MUA’s/MUP’s UDS Mapper, udsmapper.org

31. Mapping Need in RI: Section 330 Grantee Access Points UDS Mapper, udsmapper.org

32. Key Disparities in RI  GIS mapping used to target resources 30  Lead poisoning in children  At-risk populations for Tobacco Abuse "Using Geographic Information to Target Health Disparities: State Experience”, 2011.

33. Key Disparities in RI  2011 Health Disparities Profiles 31  “Rhode Island has one of the highest rates of death due to coronary heart disease” (rank 48 th in US)  “Some of the lowest rates of death due to stroke (3 rd ), unintentional injuries (11 th ) and suicide (6 th )…obesity (10 th )…and a relatively low rate or current smoking (14 th )”  High rates of preventive care (cholesterol screening, routine check up in last 2 years, dental visit in last year; placing 3 rd in each), but large disparity in rate of cholesterol screening for Hispanic population  High rates of insurance (17 th ), but significantly lower in Hispanic population “Health Disparities Profiles: 2011 Edition.” Washington, DC: DHHS Office on Women’s Health. 2011

34.  Office of Primary Care and Rural Health (OPCRH)  Possible Barriers Identified:  Access to Care  HPSA’s  Insurance/Ongoing Source of Care  Public Transportation Key Disparities in RI

35.  Office of Primary Care and Rural Health (OPCRH)  Possible Barriers Identified:  Access to Care  HPSA’s  Insurance/Ongoing Source of Care  Public Transportation Key Disparities in RI

36.  Office of Primary Care and Rural Health (OPCRH)  Possible Barriers Identified:  Access to Care  HPSA’s  Insurance/Ongoing Source of Care  Public Transportation Key Disparities in RI

37.  Office of Primary Care and Rural Health (OPCRH)  Possible Barriers Identified:  Access to Care  HPSA’s ???  Insurance/Ongoing Source of Care  Public Transportation Key Disparities in RI

38.  Office of Primary Care and Rural Health (OPCRH)  Five Barriers to ACCESSING Care  Inadequate capacity of dental services  Inadequate supply of mental health services  Lack of knowledge of resources  Individual stigma around receiving services and benefits  Inadequate public transportation

39. Trends in Rhode Island

40. In The News…

41. “House approves bill for osteopathic medicine school” May 16, 2012, http://www.rilin.state.ri.us “House approves bill for osteopathic medicine school” May 16, 2012, http://www.rilin.state.ri.us “RI to receive $6.2M in grants from Affordable Care Act” May 1, 2012, http://www.pbn.com “RI to receive $6.2M in grants from Affordable Care Act” May 1, 2012, http://www.pbn.com “UnitedHealthcare donates $250K to physicians loan forgiveness program” October 11, 2011, http://www.pbn.com “UnitedHealthcare donates $250K to physicians loan forgiveness program” October 11, 2011, http://www.pbn.com “Poverty Institute in last-ditch fight to prevent RIte Care cuts” June 14, 2011, http://blogs.wpri.comhttp://blogs.wpri.com “Poverty Institute in last-ditch fight to prevent RIte Care cuts” June 14, 2011, http://blogs.wpri.comhttp://blogs.wpri.com “Reed Urges RI Nursing and Med Students to Apply for Newly Expanded Scholarship Designed to Expand RI’s Primary Health Care Workforce” May 17, 2011, http://www.senate.govhttp://www.senate.gov “Reed Urges RI Nursing and Med Students to Apply for Newly Expanded Scholarship Designed to Expand RI’s Primary Health Care Workforce” May 17, 2011, http://www.senate.govhttp://www.senate.gov “RI Foundation Grant Supports Inspiring Mentorships” April 2011, http://www.giving.brown.edu 37http://www.giving.brown.edu 37 “RI Foundation Grant Supports Inspiring Mentorships” April 2011, http://www.giving.brown.edu 37http://www.giving.brown.edu 37 “Federal Grants to Transform Primary Care at Memorial” 2011, http://www.mhri.orghttp://www.mhri.org “Federal Grants to Transform Primary Care at Memorial” 2011, http://www.mhri.orghttp://www.mhri.org “A Focus on Primary Care: Effective Strategies for Recruiting Students” Medicine & Health, August 2011. “A Focus on Primary Care: Effective Strategies for Recruiting Students” Medicine & Health, August 2011.

42. Recent RI Legislative Actions and DOH Programs  New Osteopathic School Approved by RI House, May 16, 2012 36  Letter from “Rhode Island Primary Care Physician Advisory Committee” to RI DOH Director Dr Michael Fine, January 9, 2012 42  RI Medicaid Global Waiver Program (2008-2013) 43

43. Recent DOH Reports  Impact of Primary Care on Healthcare Cost and Population Health: A Literature Review, Feb 2012 46  “An Independent Evaluation of Rhode Island’s Global Waiver”, The Lewin Group, December 6, 2011 45  The Health of Rhode Island Non-Metropolitan Communities, 2011 22  Healthy Rhode Island 2010  Healthy RI Task Force: Getting National health Reform Right for Rhode Island, Sept 2010 32

44. Summary  Rhode Island Characteristics  Metro vs Non-metro  Barriers to access  Lower participation in programs such as WIC  Wealthier, Younger, more Caucasians, bigger divide in education  Average rates of insurance overall  Above average HC expenditure per capita

45. Summary  Workforce  Higher numbers of specialists and PC physicians  Lower rates of NP’s and PA’s  Few training programs  Lower rates of retention

46. Summary  PC Infrastructure  17 HPSA’s  RI no stranger to GIS mapping  High rates of death from CHD  Lower rates of smoking, obesity than national average  Non-metro areas with barriers to access

47. In The News  Healthcare Reform  Medicaid Budget  Support for Primary Care via loan forgiveness, mentorship programs, etc

48. Questions, Discussion…

49. References (correlate with RI_full_outline.docx) 1. http://en.wikipedia.org/wiki/Rhode_Island (accessed May 4, 2012) http://en.wikipedia.org/wiki/Rhode_Island 2. Census 2010 Quick Facts: Rhode Island, http://quickfacts.census.gov/qfd/states/44000.html (accessed May 4, 2012) http://quickfacts.census.gov/qfd/states/44000.html 3. http://news.providencejournal.com/breaking-news/2010/06/carcier-signs-law-changing- inc.html (accessed May 4, 2010) http://news.providencejournal.com/breaking-news/2010/06/carcier-signs-law-changing- inc.html 4. http://www.statehealthfacts.org/healthreformsource.jsp?rgn=41 (accessed May 3, 2012) http://www.statehealthfacts.org/healthreformsource.jsp?rgn=41 5. http://www.theagapecenter.com/Hospitals/Rhode-Island.htm#R (accessed May 7 th, 2012) http://www.theagapecenter.com/Hospitals/Rhode-Island.htm#R 6. http://blogs.wpri.com/2010/12/21/would-the-feds-file-suit-against-blue-cross-ri/ (accessed May 7 th, 2012) http://blogs.wpri.com/2010/12/21/would-the-feds-file-suit-against-blue-cross-ri/ 7. http://blogs.wpri.com/2011/03/15/gallup-ri-has-5th-biggest-rise-in-uninsured-adults/ (accessed May 7 th, 2012) http://blogs.wpri.com/2011/03/15/gallup-ri-has-5th-biggest-rise-in-uninsured-adults/ 8. “Focus on Health Reform: How Competitive Are State Insurance Markets? “ Kaiser Family Foundation, Oct 2011. 9. AAMC Physician Workforce State Profiles, https://www.aamc.org/initisiatives/workforce/reports/profiles/, accessed May 15, 2012 https://www.aamc.org/initisiatives/workforce/reports/profiles/ 10. Christian S, Dower C, O’Neil E, “Overview of Nurse Practitioner Scopes of Practice in the United States – Discussion”, Center for Health Professions, UCSF, 2007. (http://www.acnpweb.org/files/public/UCSF_Discussion_2007.pdf, accessed May 22,2012)http://www.acnpweb.org/files/public/UCSF_Discussion_2007.pdf

50. References (correlate with RI_full_outline.docx) 11. Christian S, Dower C, O’Neil E, “Chart Overview of Nurse Practitioner Scopes of Practice in the United States”, Center for Health Professions, UCSF, 2007. (http://futurehealth.ucsf.edu/Content/29/2007- 12_Overview_of_Nurse_Practitioner_Scopes_of_Practice_In_the_United_States_C hart.pdf, accessed May 15, 2012)http://futurehealth.ucsf.edu/Content/29/2007- 12_Overview_of_Nurse_Practitioner_Scopes_of_Practice_In_the_United_States_C hart.pdf 12. “Professional Issues: Physician Assistant Scope of Practice”, American Academy of Physician Assistants, Jan 2010. Pages 2-3 (http://www.aapa.org/uploadedFiles/content/Common/Files/PI_PA_Scope_Practic e_v4-052611-UPDATED.pdf, accessed May 22, 2012)http://www.aapa.org/uploadedFiles/content/Common/Files/PI_PA_Scope_Practic e_v4-052611-UPDATED.pdf 13. “PA Prescribing Authority By State”, American Academy of Physician Assistants, Jan 2012. Pages 1-2. (http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Sta te_Affairs/Resource_Items/Rx%20Chart%201-12.pdf, accessed May 22, 2012)http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Sta te_Affairs/Resource_Items/Rx%20Chart%201-12.pdf 14. “Total Nurse Practitioners, 2011”, Kaiser Family Foundation, http://www.statehealthfacts.org/comparemaptable.jsp?ind=773&cat=8 (accessed May 22, 2012) http://www.statehealthfacts.org/comparemaptable.jsp?ind=773&cat=8 15. “Total Physician Assistants, 2011”, Kaiser Family Foundation, http://www.statehealthfacts.org/comparemaptable.jsp?ind=440&cat=8 (accessed May 22, 2012) http://www.statehealthfacts.org/comparemaptable.jsp?ind=440&cat=8

51. References (correlate with RI_full_outline.docx) 16. Rhode Island, Physician Assistants: State Laws and Regulations, 12 th Edition, January 2011. R.I. GEN LAWS §5-54-8, and 14-140-033 R.I. CODE R. §1.10 as accessed from http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Rhode%20Island%202011.pdf (accessed May 22, 2012) http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Rhode%20Island%202011.pdf 17. Connecticut, Physician Assistants: State Laws and Regulations, 12 th Edition, January 2011. CONN. GEN. STAT. §20-12d, CONN. GEN. STAT. §20-12a(7)(A), and CONN. GEN. STAT. §20-12a(7)(B), as accessed from http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Connecticut%202011.pdf (accessed May 22, 2012) http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Connecticut%202011.pdf 18. Massachusetts, Physician Assistants: State Laws and Regulations, 12 th Edition, January 2011. MASS. GEN. LAWS ch. 112, §9E, MASS. GEN. LAWS ch. 94C, §7(g), and 263 MASS. CODE REGS. 5.07, as accessed from http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Massachusetts%202011.pdf (accessed May 22, 2012) http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Massachusetts%202011.pdf 19. Maine, Physician Assistants: State Laws and Regulations, 12 th Edition, January 2011. 02-373-2 ME. CODE R. §6 and 02-373-2 ME. CODE R. §6(A)(2), as accessed from http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Maine%202011.pdf (accessed May 22, 2012) http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Maine%202011.pdf

52. References (correlate with RI_full_outline.docx) 20. New Hampshire, Physician Assistants: State Laws and Regulations, 12 th Edition, January 2011. N.H. CODE ADMIN. R. ANN. MED 603.01 and N.H. CODE ADMIN. R. ANN. MED 612. 01, as accessed from http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/New%20Hampshire%202011.pdf (accessed May 22, 2012) http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/New%20Hampshire%202011.pdf 21. Vermont, Physician Assistants: State Laws and Regulations, 12 th Edition, January 2011. 13-141-001 VT. CODE R. §5.1 and VT. STAT. ANN. tit. 26 §1735 and 13-141-001 VT. CODE R. §5.2, as accessed from http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Vermont%202011.pdf (accessed May 22, 2012) http://www.aapa.org/uploadedFiles/content/The_PA_Profession/Federal_and_Stat e_Affairs/Resource_Items/Vermont%202011.pdf 22. “The Health of Rhode Island Non-Metropolitan Communities”, Office of Primary Care and Rural Health, November 2011. 23. Fact Finder 2, US Census Bureau, http://factfinder2.census.gov/, accessed May 23, 2012

53. References (correlate with RI_full_outline.docx) 24. ACGME data from AMA-MF 25. Data from freq.xlsx (AMA-MF per Newton) 26. Tuition and Student Fees Reports, AAMC, http://services.aamc.org/tsfreports/select.cfm?year_of_study=2010, accessed May 23,2012 http://services.aamc.org/tsfreports/select.cfm?year_of_study=2010 27. RI AHEC Primary Care Mapping Project http://med.brown.edu/ahec/mapping_project/, accessed May 23, 2012http://med.brown.edu/ahec/mapping_project/ 28. UDS Mapper, http://www.udsmapper.org, accessed May 23, 2012http://www.udsmapper.org 29. Rhode Island: Health Professional Shortage Areas, Kaiser Family Foundation, http://www.statehealthfacts.org/profileind.jsp?cat=8&sub=156&rgn=41, accessed May 23,2012 http://www.statehealthfacts.org/profileind.jsp?cat=8&sub=156&rgn=41 30. Osborn D, Hinkle L, Rosenthal J. “Using Geographic Information to Target Health Disparities: State Experience”, Healthcare Utilization Project, Sept 23, 2011. (p 5-6) 31. “Health Disparities Profiles: 2011 Edition.” Washington, DC: DHHS Office on Women’s Health. 2011. 32. “Healthy RI Task Force Report: Getting national health Reform Right for Rhode Island”, September 2010. http://www.ltgov.ri.gov/taskforce/Healthy%20RI%20Task%20Force%20Report%2009.23.1 0.pdf, accessed May 15, 2012. http://www.ltgov.ri.gov/taskforce/Healthy%20RI%20Task%20Force%20Report%2009.23.1 0.pdf

54. References (correlate with RI_full_outline.docx) 33. “Poverty Institute in last-ditch fight to prevent RIte Care cuts”, June 14, 2011, http://blogs.wpri.com/2011/06/14/poverty-institute-in-last-ditch-fight-to-prevent- rite-care-cuts/, accessed May 2, 2012. http://blogs.wpri.com/2011/06/14/poverty-institute-in-last-ditch-fight-to-prevent- rite-care-cuts/ 34. “Reed Urges RI Nursing and Med Students to Apply for Newly Expanded Scholarship Designed to Expand RI’s Primary Health Care Workforce”, May 17, 2011, http://www.reed.senate.gov/news/release/reed-urges-ri-nursing-and-med- students-to-apply-for-newly-expanded-scholarship-designed-to-expand-ris-primary- health-care-workforce, accessed 5/17/2012. http://www.reed.senate.gov/news/release/reed-urges-ri-nursing-and-med- students-to-apply-for-newly-expanded-scholarship-designed-to-expand-ris-primary- health-care-workforce 35. “UnitedHealthcare donates $250K to physicians loan forgiveness program”, October 11, 2011, http://www.pbn.com/UnitedHealthcare-gives-250000-to-improve-access- to-primary-care,61803, accessed May 17, 2012.http://www.pbn.com/UnitedHealthcare-gives-250000-to-improve-access- to-primary-care,61803 36. “House approves bill for osteopathic medicine school”, May 16, 2012, http://www.rilin.state.ri.us/News/pr1.asp?prid=8308, accessed May 17, 2012. http://www.rilin.state.ri.us/News/pr1.asp?prid=8308 37. “RI Foundation Grant Supports Inspiring Mentorships”, April 2011, http://giving.brown.edu/features/11-RIFoundation, accessed May 17, 2012. http://giving.brown.edu/features/11-RIFoundation 38. “Primary Healthcare Reform: A Signature Initiative”, RI Foundation, http://www.rifoundation.org/Home/OurSignatureInitiatives/PrimaryHealthcareRef orm/tabid/854/Default.aspx, accessed May 17, 2012. http://www.rifoundation.org/Home/OurSignatureInitiatives/PrimaryHealthcareRef orm/tabid/854/Default.aspx

55. References (correlate with RI_full_outline.docx) 39. Anthony D, MacNamara M, George P, Taylor JS. “A Focus on Primary Care: Effective Strategies for Recruiting Students”, Medicine & Health, August 2011, 94(8):230-233. 40. Physician Visa Waiver Program, RI Dept of Health, http://www.health.ri.gov/programs/physicianvisawaiver, accessed May 17, 2012. http://www.health.ri.gov/programs/physicianvisawaiver 41. “RI to receive $6.2M in grants from Affordable Care Act”, May 1, 2012, http://www.pbn.com/RI-to-receive-62M-in-grants-from-Affordable-Care-Act,67248, accessed May 2, 2012. http://www.pbn.com/RI-to-receive-62M-in-grants-from-Affordable-Care-Act,67248 42. Letter from “Rhode Island Primary Care Physician Advisory Committee” to RI DOH Director Dr Michael Fine, January 9, 2012. http://www.acponline.org/about_acp/chapters/ri/lange_12.pdf, accessed May 23, 2012 http://www.acponline.org/about_acp/chapters/ri/lange_12.pdf 43. “RI Medicaid Global Waiver (2008-2013)”, PowerPoint presentation by Secretary of EOHHS, 2010. http://icvclients.com/nescso/rhodeisland_presentations/global_waiver/, accessed May 2, 2012. http://icvclients.com/nescso/rhodeisland_presentations/global_waiver/ 44. “Medicaid: An Overview of Spending on ‘Mandatory’ vs. ‘Optional’ Populations and Services”, Kaiser Commission on Medicaid and the Uninsured, June 2005. http://www.kff.org/medicaid/upload/Medicaid-An-Overview-of-Spending-on.pdf, accessed on May 23, 2012. (page 2) http://www.kff.org/medicaid/upload/Medicaid-An-Overview-of-Spending-on.pdf

56. References (correlate with RI_full_outline.docx) 45. “An Independent Evaluation of Rhode Island’s Global Waiver”, The Lewin group, December 6, 2011. http://www.eohhs.ri.gov/documents/documents11/Lewin_report_12_6_11.pdf, accessed May 23, 2012. http://www.eohhs.ri.gov/documents/documents11/Lewin_report_12_6_11.pdf 46. Frugé D, “Impact of Primary Care on Healthcare Cost and Population Health: A Literature Review”, RI Dept of Health, Feb 23, 2012. 47. “Federal Grants to Transform Primary Care at Memorial”, 2011, www.mhri.org/ss_plugins/content/content.php?content.2220, accessed May 17, 2012. www.mhri.org/ss_plugins/content/content.php?content.2220 48. “Analytical Report on Primary Care Workforce Shortages, Trends, and Policy Options”, Robert Graham Center, 2011. ??? 49. The Economic Progress Institute, http://www.economicprogressri.org/About/AboutTheInstitute/tabid/198/Default.a spx, accessed May 25, 2012. http://www.economicprogressri.org/About/AboutTheInstitute/tabid/198/Default.a spx