1. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Session 3141: Health Administration Roundtable I - Workforce Issues Yvette Mendez, MPA The Rhode Island Foundation Cindy J Wong, PhD Research & Evaluation Consultant American Public Health Association (APHA) 141 st Annual Meeting Boston, MA Monday, November 4, 2013 10:30 am-12:00 pm BCEC 255

2. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Overview: The Affordable Care Act (ACA) is expected to substantially raise the numbers of Americans with health insurance across the country. Primary care provider (PCP) shortages are predicted to intensify as a result of the national health reform. To measure the ACA's potential impact on the primary care workforce in Rhode Island, a situational analysis was completed. This presentation will discuss current statewide workforce initiatives and the results of the analysis. Our research questions were: How many PCPs are active in Rhode Island? How many are needed? What is the potential impact of health reform on the primary care workforce? Learning Objectives: Identify data sources for health workforce study; Analyze potential impact of ACA on primary care workforce in states and counties

3. Measuring the Potential Impact of Health Reform on the Primary Care Workforce “ The experiences of other industrialized countries show that ensuring access to primary care – one of the goals of U.S. health reform – can provide the groundwork for efforts to improve overall care and population health while also controlling costs. ” -Robert L. Phillips, Jr., M.D., M.S.P.H., in the Journal of the American Board of Family Medicine

4. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Primary care is essential in building a robust health care system that contributes to: Lowered costs Improvements in quality Expanded access to care

5. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Health Reform – Affordable Care Act (ACA) Increase the Number of Americans with Health Insurance Increase the Demand for Primary Care Services Lead to Shortages in Primary Care Workforce (?)

6. Measuring the Potential Impact of Health Reform on the Primary Care Workforce The Robert Wood Johnson Foundation & Urban Institute estimate: 27.8 million nonelderly adults will enroll in health insurance in the U.S. The national uninsurance rate will fall from 18.6 to 8.3% The greatest decline will be in the lowest- income populations Source: The Robert Wood Johnson Foundation/Urban Institute 2010

7. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Research Questions - The Rhode Island Foundation How many primary care providers are practicing in Rhode Island per 100,000 population? How many are needed? What impact will the health care reform have on the primary care workforce?

8. Measuring the Potential Impact of Health Reform on the Primary Care Workforce How many Primary Care Providers are in Rhode Island? 2011# Primary Care Providers (PCPs) Census Population 2011 PCPs per 100,000 population Rhode Island 1,2331,051,302117.3 Bristol County 8949,800178.7 Kent County 155165,53593.6 Newport County 7982,69595.5 Providence County 772626,709123.2 Washington County 138126,563109.0 Source: Health Resources and Services Administration (HRSA), Area Health Resource File 2012-2013 (AHRF) http://arf.hrsa.gov/. Notes: The most recent AHRF (2012-2013) reports 2011 primary care provider figures. AHRF includes the following health professions under primary care: medical doctors (MD), doctors of osteopathic medicine (DO), and physician assistants (PA). The primary care providers in the table includes the total number of: non-federal, non-resident MDs and DOs, and active physician’s assistants. The calculation excludes: physician/MD/DO hospital residents and inactive physician assistants. The AHRF does not include nurse practitioner data in primary care providers. The ratio per 100,000 is calculated using 2011 U.S. Census population estimate for RI accessed from the same file (AHRF 2012-2013).http://arf.hrsa.gov/

9. Measuring the Potential Impact of Health Reform on the Primary Care Workforce How many Primary Care Providers are needed? Selected Benchmarks HRSA Health Professional Shortage Area (HPSA) designation = 50 primary care providers per 100,000 population Council on Graduate Medical Education (COGME) federal advisory committee recommendation = 60 to 80 providers per 100,000 population Sources: Health Resources and Services Administration: Primary Medical Care HPSA Designation Overview http://bhpr.hrsa.gov/. Council on Graduate Medical Education. (1996, November). Patient Care Physician Supply and Requirements: Testing COGME Recommendations http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/.http://bhpr.hrsa.gov/http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/

10. Measuring the Potential Impact of Health Reform on the Primary Care Workforce RI Primary Care Providers (MD/DO/PA) per 100,000 with HRSA Benchmark (2010-2011) Sources: Health Resources and Services Administration (HRSA), Area Resource File 2011-2012 (ARF) and Area Health Resource File 2012-2013 (AHRF) http://arf.hrsa.gov HRSA Primary Care Health Professional Shortage Area: < 50 PCPs per 100,000 population

11. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Sources: Health Resources and Services Administration (HRSA), Area Resource File 2011-2012 (ARF) and Area Health Resource File 2012-2013 (AHRF) http://arf.hrsa.gov COGME Adequate PCP Benchmark: 60-80 PCPs per 100,000 population

12. Measuring the Potential Impact of Health Reform on the Primary Care Workforce HRSA-Designated Primary Care Health Professional Shortage Areas 2013 Bristol County: No HPSAsProvidence County: Kent County: No HPSAs Rhode Island Adult Correctional Institution Newport County: Thundermist Healthcare East Bay Community Action Program Blackstone Valley Community Healthcare Washington County: Providence Community Health Center Bayside Family Healthcare, Inc. Northwest Community Health Center Wood River Health Services Chad Brown Health Center Narrangansett Indian Tribe Health Program Tri-Town Community Action Program Providence County: Comprehensive Community Action, Inc. Woonsocket City Providence City Central Falls City Pawtucket City Source: Health Resources and Services Administration: Shortage Designation: Health Professional Shortage Areas & Medically Underserved Areas/Populations Retrieved 10/31/2013 from http://bhpr.hrsa.gov/shortage/index.html

13. Measuring the Potential Impact of Health Reform on the Primary Care Workforce What is the potential impact of the Affordable Care Act (ACA) on the PCP workforce in Rhode Island? 125,029 persons < 65 without health insurance (2012) 14.3% Uninsurance Rate Statewide (2012) 15.7% Uninsurance Rate Providence County (2009) 70% of Rhode Island’s total uninsured population resides in Providence County Sources: The Economic Progress Institute (2013 Sept) Press Release: 125,000 Rhode Islanders under Age 65 Lacked Health Insurance in 2012. http://www.economicprogressri.org. Health Resources and Services Administration (HRSA), Area Health Resource File 2012-2013 (AHRF) http://arf.hrsa.gov/.http://arf.hrsa.gov/

14. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Rhode Island Uninsurance Rates & PCPs Needed per Uninsured Population Gaining Coverage under ACA Persons < 65 without Health Insurance (2012) < 65 Uninsurance Rate (2012) Rhode Islanders Newly Eligible for Coverage via ACA Medicaid Expansion Rhode Islanders Newly Eligible for Coverage via RI Healthcare Exchange Total Rhode Islanders Newly Eligible for Coverage Under ACA Rhode Island Statewide 125,02914.3%45,00044,00089,000 PCPs needed for Rhode Islanders who are newly eligible for health insurance coverage under ACA ‡ 27.0 - 36.026.4 - 35.253.4 - 71.2 Sources: The Economic Progress Institute (2013 Sept) Press Release: 125,000 Rhode Islanders under Age 65 Lacked Health Insurance in 2012. http://www.economicprogressri.org. Council on Graduate Medical Education (1996), Patient Care Physician Supply and Requirements: Testing COGME Recommendations. ‡ The number of PCPs needed is calculated using COGME benchmark of 60-80 PCPs per 100,000 and the estimated number of uninsured Rhode Islanders who will gain eligibility for coverage, as reported by The Economic Progress Institute.

15. Measuring the Potential Impact of Health Reform on the Primary Care Workforce 1 in 4 Rhode Island physicians will reach retirement age in the next 5 years: 25% Age 60+ years Total Active Physicians in Rhode Island (2010) = 3,500 Active Physicians near Retirement Age (60+ yrs) = 825 Source: Association of American Medical Colleges, 2011 State Physician Workforce Book: Rhode Island Physician Workforce Profile https://www.aamc.org/download/152172/data/rhode_island.pdf https://www.aamc.org/download/152172/data/rhode_island.pdf

16. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Primary Care – Provider Workforce Take into account retirement rates on local and state levels, and replacement with new primary care providers Recruitment of medical students to primary care practice Future innovations in health delivery – how to assess the potential in increasing primary care workforce capacity Inclusion of other qualified professionals (e.g. nurse practitioners) in increasing primary care workforce capacity

17. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Primary Care – Population Needs Consider access to and distribution of providers by locality, insurance, and institution **How many primary care providers accept Medicaid ?** Medically underserved communities that already have unmet needs for primary care - will have even greater needs for primary care under ACA Communities with growing and aging populations (in the general population and among physicians) - will have increasing demands for primary care services

18. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Closing Remarks Difficult to predict the precise impact of ACA in 2014 due to different reasons: Limitations in data & the analytic model Uncertainty in future politics and legislation However, with increasing availability of online primary source trending data (e.g. AHRF/ARF) as well as census population, and benchmarks (e.g. HPSA/COGME) We have tools to continue to assess workforce issues, evaluate the trends, and to plan and leverage resources in the changing health policy landscape

19. Measuring the Potential Impact of Health Reform on the Primary Care Workforce This presentation is based on: Working Paper: Rhode Island Primary Care Providers - Implications of Health Reform (Fall 2012) Prepared for The Rhode Island Foundation by: Cindy Wong, PhD, Research & Evaluation Consultant cindy@cindyjwongresearch.net (831) 531-2661

20. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Data Sources: COGME Benchmark for Adequacy of Primary Care Providers: Council on Graduate Medical Education. (1996, November). Patient Care Physician Supply and Requirements: Testing COGME Recommendations http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/eighthr eport.html http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/eighthr eport.html HRSA Benchmark for Primary Care Health Professional Shortage Area: Health Resources and Services Administration: Primary Medical Care HPSA Designation Overview http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/primarycarehpsaovervi ew.html http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/primarycarehpsaovervi ew.html Primary Care Health Professional Shortage Areas (Localities& Facilities): Health Resources and Services Administration: Shortage Designation: Health Professional Shortage Areas & Medically Underserved Areas/Populations http://www.hrsa.gov/shortage/find.html http://www.hrsa.gov/shortage/find.html

21. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Data Sources (continued): Primary Care Providers; Census Populations (States & Counties): Health Resources and Services Administration (HRSA): Area Health Resource File 2012-2013 (AHRF) and Area Resource File 2011-2012. http://arf.hrsa.gov/ http://arf.hrsa.gov/ Primary Care Physicians Workforce (States): Association of American Medical Colleges (AAMC): 2011 State Physician Workforce Data Book https://www.aamc.org/download/263512/data https://www.aamc.org/download/263512/data Rhode Islander Uninsurance Rates 2012 & Anticipated Number of Newly Eligible Under ACA: The Economic Progress Institute (2013 Sept) Press Release: 125,000 Rhode Islanders under Age 65 Lacked Health Insurance in 2012. http://www.economicprogressri.org. http://www.economicprogressri.org Infographic in Handout: Doctor by Andrew McKinley from The Noun Project. http://thenounproject.com. http://thenounproject.com

22. Measuring the Potential Impact of Health Reform on the Primary Care Workforce Contact Information: Yvette Mendez, MPA The Rhode Island Foundation One Union Station Providence, RI 02903 (401) 427-4051 ymendez@rifoundation.org Cindy J Wong, PhD Research and Evaluation Consultant 7960 Soquel Drive, B145 Aptos, CA 95003 (831) 531-2661 cindy@cindyjwongresearch.net