1. UNC Family Medicine Alumni Weekend April 13, 2017
 Health Workforce Trends and Challenges in North Carolina and the United States
Erin P. Fraher, PhD, MPP
Assistant Professor, Department of Family Medicine
Director, Program on Health Workforce Research & Policy
Cecil G. Sheps Center for Health Services Research, UNC-CH
UNC Family Medicine Alumni Weekend April 13, 2017

2. Fears of physician shortages create headlines but we see steady increase in supply
Physicians per 10,000 population, North Carolina and United States,
Sources: North Carolina Health Professions Data System, 1979 to 2013; American Medical Association Physician Databook, selected years; US Census Bureau; North Carolina Office of State Planning. North Carolina physician data include all licensed, active, physicians practicing in-state, inclusive of residents in-training and federally employed physicians, US data includes total physicians in patient care, which is inclusive of residents-in-training and federally employed physicians.US physician data shown for 1980, 1985, 1990, 1994, 1995, 2004, 2005, 2007, 2009, 2011, 2012, 2013; all other years imputed.

3. The real issue is maldistribution
The real issue is maldistribution. Gap between shortage and non-shortage counties is growing
Physicians per 10,000 population by Persistent Health Professional Shortage Area (PHPSA) Status, North Carolina,
Not a PHPSA
Gap: 9.4 physicians per 10K pop
Gap: 3.8 physicians per 10K pop
The 2016 PHPSA Breakdown is:
Partial County: 63
Whole County: 16 (see below list)
Non-PHPSA: 21
The Non-PHPSAs include some counties that should qualify for PHPSA status but don’t have it. (I guess because they didn’t fill out the paperwork? Chris Collins used to bring this up when we discussed HPSAs when she was ORH director.) The slide shows a conservative estimate of the gap between the non-PHPSA and whole county PHPSAs since HPSAs are not a comprehensive measure of underservice. For example, Camden County hasn’t had a physician with a primary practice location in the county since 2011, but it has not had HPSA status since 1982 per the AHRF so it is grouped in the “non-PHPSA” counties. If we had a better official way to estimate primary care shortages, the gap between well-resourced and under-resourced counties would likely be larger.
Whole County PHPSAs 2016
Anson, Beaufort, Clay, Currituck, Dare, Gates, Graham, Harnett, Hoke, Hyde, Montgomery, Northampton, Robeson, Stokes, Tyrrell, Washington
Whole County PHPSA
Notes: Figures include active, instate, nonfederal, non-resident-in-training physicians licensed as of October 31st of the respective year. North Carolina population data are smoothed figures based on 1980, 1990, 2000 and 2010 Censuses. Persistent HPSAs are those designated as HPSAs by HRSA in the Area Health Resource File using most recent 7 HPSA designations ( , 2015). Sources: North Carolina Health Professions Data System, 1980 to 2015; North Carolina Office of State Planning; North Carolina State Data Center, Office of State Budget and Management; Area Health Resource File, HRSA, Department of Health and Human Services.

4. 20 NC counties have comparatively few primary care physicians; 3 counties have none
Notes: Data include active, licensed physicians in practice in North Carolina as of October 31 of each year who are not residents-in-training and are not employed by the Federal government. Physician data are derived from the North Carolina Board of Medicine. County estimates are based on primary practice location. Population census data and estimates are downloaded from the North Carolina Office of State Budget and Management via NC LINC and are based on US Census data. Source: North Carolina Health Professions Data System, Program on Health Workforce Research and Policy, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Created October 5, 2017 at

5. Closures of obstetric delivery units in rural NC have made state and national headlines
Animated: rural hospitals are dying is the last graphic

6. Fewer Family Medicine physicians deliver babies now than in past
OBGYN
It could be a few big practices or it could be that older family physicians did ob and newer ones don’t. Cite work by Lars et al using ABFM data
Family Medicine
Note: Data include active, instate , nonfederal, non-resident-in-training physicians licensed in North Carolina as of October 31 of each year who reported that they provide obstetric deliveries. Specialties are based on self-reported Primary Area of Practice. Sources: North Carolina Health Professions Data System, with data from the North Carolina Medical Board..

7. The 4% of Family Medicine physicians who provide obstetric deliveries are clustered in western and central counties
Family Medicine Physicians Who Provide Routine Obstetric Deliveries
per 10,000 Childbearing Age* Females, North Carolina, 2011
Nonmetropolitan County (54)
Note: *Childbearing age: years. Data include active, instate , nonfederal, non-resident-in-training physicians licensed in North Carolina as of October 31, 2011 who reported a primary area of practice of “Family Medicine.” Sources: North Carolina Health Professions Data System, with data from the North Carolina Medical Board, 2011; US Census Bureau and Office of Management and Budget, 2013.

8. Access to behavioral health services are growing issue: why doesn’t anyone want to become a psychiatrist?
Physicians and Psychiatrists per 10,000 Population, North Carolina,
NUMBERS DIFFER FROM EARLIER SLIDE. REFLECTS AMAMF VS HPDS NUMBER DIFFERENCES.
Half of NC counties are mental health professional shortage areas
Data from HPDS Data System at Cecil G. Sheps Center, University of North Carolina at Chapel Hill

9. It is not just about physicians: Rapid growth in NP & PA workforce
Cumulative Rate of Growth per 10,000 Population Since 2000: Physicians, Nurse Practitioners and Physician Assistants in North Carolina
Explosive growth of NPs and PAs compared to physicians over the past 15 years. NPs and PAs are increasingly taking on tasks/roles historically provided by physicians, unclear what is substitution vs complementary, but clear will continue to play a major role in health system
S:\RWJ_Nursing\Yin's work\NP&PA_2011 update\CumulativeRateOfGrowthSince2000_NP_PA_MD_30Jan2017JCS.xlsx
Sources: North Carolina Health Professions Data System with data derived from the North Carolina Medical Board and North Carolina Board of Nursing, 2000 to Figures include all active, instate, non-federal, non-resident-in-training physicians, and all active, instate PAs and NPs licensed as of October 31 of the respective year. Produced by: Program on Health Workforce Research and Policy, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.

10. Are NPs and PAs the answer. Maybe not
Are NPs and PAs the answer? Maybe not. There is a widening gap between NP supply in rural and urban counties
Nurse Practitioners per 10,000 by Metropolitan and Nonmetropolitan Counties, North Carolina, 1979 to 2014
Produced by: Program on Health Workforce Research and Policy, Sheps Center for Health Services Research, UNC-CH.

11. Like their physician colleagues, NPs and PAs are also specializing…
Percent of Nurse Practitioners and Physician Assistants Reporting a Primary Care Specialty, *, North Carolina
Notes: Data for primary specialty include active, in-state NPs indicating a primary specialty of family practice, general practice, internal medicine, Ob/Gyn, or pediatrics, who were licensed in NC as of October 31 of the respective year. Data for physician extender type include active-instate NPs indicating a physician extender type of family nurse practitioner, adult nurse practitioner, ob/gyn nurse or pediatric nurse practitioner who were licensed as of October 31 of the respective year. Source: North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, with data derived from the NC Medical Board. Chart prepared on 12/07/2012.

12. It’s not going to address maldistribution
Policy makers say: “Let’s make more doctors! We’ll expand medical school enrollment.”
It’s not going to address maldistribution

13. Most NC med students leave NC and don’t practice in needed specialties and geographies
NC Medical Students: Retention in Primary Care in NC’s Rural Areas
6 (1%)
Total Number of 2011 NC med school graduates in training or practice as of 2016:
431
Initial residency in primary care in 2011
252 (58%)
In training/practice in primary care in 2016:
142 (33%)
Julie updated Oct 2016
Total NC School of Medicine Graduates in 2010 = 420
5 graduates not in practice in 2015 (1 deceased, 1 moved abroad, 3 no longer working as physicians)
In primary care in NC in 2016:
60 (16%)
In PC in rural NC:
Source: North Carolina Health Professions Data System with data derived from the Association of American Medical Colleges, and the NC Medical Board, Rural source: US Census Bureau and Office of Management and Budget, July ”Core Based Statistical Area” (CBSA) is the OMB’s collective term for Metropolitan and Micropolitan Statistical areas. Here, nonmetropolitan counties include micropolitan and counties outside of CBSAs.
Produced by the Program on Health Workforce Research and Policy, Sheps Center for Health Services Research, UNC-CH.

14. Retention after residency training looks equally bad
We tracked the outcomes five years after graduation for:
2,009 physicians who graduated from NC residency programs in 2008, 2009, 2010 or for specialties identified as being in shortage by the NC General Assembly*
853 (42%) were in practice in North Carolina five years after graduation
65 (3%) were in practice in rural North Carolina counties five years after graduation
12 (0.6%) Family Medicine
4 (0.2%) General Pediatrics
4 (0.2%) General Surgery
4 (0.2%) General Internal Medicine
4 (0.2%) Obstetrics & Gynecology
13** (0.6%) General Psychiatry
14 (0.7%) Other specialties*
Notes: The workforce outcomes of four cohorts of residents who completed training in 2008, 2009, 2010, or 2011 were analyzed. We used North Carolina Medical Board licensure data to determine the location and primary area of practice for each physician five years after graduation, e.g., for a resident who completed training in 2008, we used 2013 NC Medical Board data to determine his/her location and primary area of practice. *North Carolina Session Law , Section 11J.2. Includes anesthesiology, neurology, neurological surgery, obstetrics and gynecology, family medicine, internal medicine, internal medicine/pediatrics, pediatrics, psychiatry, surgery, and urology. **Central Regional Hospital and affiliated state psychiatric facilities are located in Granville County, which is a nonmetro county. At least 6 of these psychiatrists were employed by the state in Granville County. Source: NC Health Professions Data System, Cecil G. Sheps Center for Health Services Research, UNC-CH, with data derived from the North Carolina Medical Board.

15. Need to invest in more training tracks like the FIRST program: Retention much higher if complete both med school and residency instate
As of 2014:
Julie updated on 30 Jan All percentages are the same as from 2013 databook.
Per AAMC 2015 State Databook, NC medical graduates stay in state (AMA MF 2014 data)
49% NC medical grads who attend a PUBLIC medical school stay in state (AMA MF 2014 data)
42% NC Residency Grads stay in state (AMA MF 2014 data)
Combined UME & GME in NC – 67% stay in state (AMA MF 2014 data)
Graphic in "S:\HPDS_Projects\Physician Training Fact Sheet\GME fact sheet 2012\layout\graphics\pptGraphic_NCMedEdRetentionmap ai"
Source: AAMC 2015 State Data Book, with data derived from the 2014 AMA Physician Masterfile.

16. Sort of interested in workforce
Sort of interested in workforce? Have a play with our data visualizations

17. In May 2017, converted Data Book to online, interactive data visualization tool
Explore 15 years of data on over a dozen health professions in NC
Total supply, supply per 10K, percent female, percent over 65, percent minority
State and county-level data
Interactive map and bar charts
Can download data for use in presentations or for analysis
nchealthworkforce.sirs.unc.edu

18. DocFlows App provides states with data on migration of residents after training
Data visualization tool allows users to query, download and share maps showing interstate moves by residents and actively practicing physicians in 36 specialties
Stakeholders: HRSA, COGME, MedPAC, ACGME, professional associations, state policy makers 
DocFlows available at: docflows.unc.edu
Users can see import, export and net flows between states

19. Questions? Want to know more?
Erin Fraher
(919)
Director
Program on Health Workforce Research and Policy, and the
North Carolina Health Professions Data System