Health care constantly evolves and shifts, in policy and practice. Iowa providers need to innovate to provide the best care.
But you can’t do that if you don’t have enough doctors.
Health care experts and policy makers have found that nationwide, and strikingly in Iowa, there are not enough primary care and specialty physicians to meet the demand for patient care.
Of all 50 states, the Hawkeye State ranked 46th in 2016 for the total number of physicians active in patient care per 100,000 people, according to the Association of American Medical Colleges, the not-for-profit that represents all the medical schools in the United States.
And that disparity is expected only to get worse. According to a 2016 Association of American Medical Colleges’ report, the demand for physicians is growing faster than the supply.
In every scenario the report accounted for — including retirement, millennial hours worked and residency expansion — it’s expected to become a “projected total physician shortfall of between 61,700 and 94,700 physicians by 2025” nationwide.
The Robert Graham Center — the research institute for the American Academy of Family Physicians — said Iowa needs at least 119 more primary care physicians — a 5 percent increase — by 2030 “to maintain current primary care utilization rates.” And that doesn’t include the demand for specialists.
“The shortage will definitely be a challenge, but it is already encouraging us to be innovative,” said Dan Varnum, president and chief executive officer of Mercy Medical Center-North Iowa in Mason City.
Health care providers, large and small, across the state are ramping up efforts to recruit and retain physicians at a rate that is enough to address patient needs — a feat that has become more costly, more time-consuming and has grown to be a concern even outside hospital walls.
Why Is This An Issue?
In a general sense, the physician workforce shortage looks the same in any other industry. Throughout the country, the largest segment of the workforce population — the baby boomer generation, born between 1946 and 1964 — is retiring.
“That’s the bigger workforce problem we have as a whole as a country,” said Nathan Piller, director of marketing in the upper Midwest at Merritt Hawkins. Merritt Hawkins is the largest physician recruiting firm in the state and has about 40 placements in the state a year.
An aging population as well as the recent trend of increased diagnoses of multimorbidity — multiple chronic conditions — indicates an increased need for health care in the near future.
In addition, experts say there are not enough doctors in training to fill the gap in health care professionals left behind by baby boomers.
“There aren’t enough physician training residencies or fellowships throughout the United States to fill that gap,” Varnum said.
According to the Association of American Medical Colleges, medical schools expanded enrollment by 30 percent between 2006 and 2016, but the problem lies in that there has not been a proportionate increase in residency positions.
The Balanced Budget Act of 1997 put a chokehold on the number of allopathic and osteopathic residency positions in the United States by limiting Medicare payments to teaching hospitals for residency and fellowship training.
The federal legislation limits positions to a degree that the number of first-year medical students “soon could exceed” the number of first-year accredited residency positions, an Association of American Medical Colleges report stated.
Solution: Training and Retaining Iowa Residents
There’s been no movement on the federal level to reform the impact the Balanced Budget Act of 1997 has on the number of residency positions in the U.S., so on a state level, the concern lies in attracting those who already have obtained their degrees.
Iowa may not be an alluring state to those who grew up in other areas, with its absence of mountains, oceans or large metro areas, but it is enticing to those who were born and grew up here, such as Dr. Trisha Thoma.
Thoma was recruited to the Mason City Clinic seven months ago as an otolaryngologist, a surgical subspecialty that deals with conditions of the ears, nose and throat and related structures of the head and neck.
She grew up in Ames and attended the University of Iowa Carver College of Medicine before going on to a five-year residency at Louisiana State University Health Sciences Center in Shreveport, La. There, she met her husband, Dr. Steven Thoma, who was in residency to become a urologist.
But as with many Iowa towns, the population has been in steady decline. There were 28,000 people living there, according to the 2010 Centers for Disease Control and Prevention Census, but the 2016 estimate found a few thousand fewer.
The Thomas officially joined the clinic in September of last year.
Both the Mason City Clinic and Mercy Medical Center-North Iowa have focused their recruitment on connecting with former Iowans currently in medical training. Executives even are reaching out to local residents who have family members in medical training to appeal to them to help bring those relatives to town.
The Mason City Chamber of Commerce joined the effort over the past year by establishing a “concierge” service during interviews for the candidate and his or her spouse. A chamber employee creates welcome packages, offers tours of Mason City and arranges meetings with real estate agents and the local school district.
Robin Anderson, president and chief executive officer of the chamber, said physician shortages affect everyone, not just those who need health care. The Mason City health care providers are some of the area’s largest employers, she said.
Association of American Medical Colleges 2016 statistics show that nearly 61 percent of those who graduated from medical school and completed their residency in-state stayed in Iowa to practice.
Iowa retained about 22 percent of students who just graduated from a medical school in the state, and 35.7 percent of those who came to Iowa to complete residency or fellowship programs.
“The good news is when we bring folks to Iowa, usually they’re high-qualified candidates, they have ties, they’re geographically motivated,” said Piller at Merritt Hawkins. “There’s a reason they want to come here.
“Once in Iowa, it’s less likely they’ll leave the state.”
What Do Candidates Look For?
Trisha and Steven Thoma — ages 31 and 32, respectively — said they wanted to live in either his home state of Louisiana or hers of Iowa to be closer to family. They started their job search about two years before they completed their residency training in May 2017.
The couple said they looked for a good quality of life when searching for their next stop, specifically taking note of the level of compensation they would receive, the amount of time they would need to work and the level of autonomy they had in an organization.
“We wanted to be a part of a community but also not have to deal with big city living,” Trisha said.
It was the Mason City Clinic that ultimately offered those qualities, as well as a culture and a town that “felt right” to them, Trisha said.
While it is a slower pace of life, their opportunities aren’t limited. Along with 39 other physician specialists at the clinic, they provide care for residents across Northern Iowa and southern Minnesota through outreach clinics that take place about 100 times a month.
“We take care of a lot of patients,” Thoma said. “We both do the full spectrum of our specialties, and it was sort of the best of both worlds.”
The Thomas’ attention to work-life balance is not unique among younger job seekers, health care executives and recruitment experts say.
To make their facilities attractive to these potential hires, health care officials have changed their thinking to meet candidates where they are.
In line with the rest of their generation, newer graduates are seeking a better work-life balance and are not keen to accept positions that require a lot of on-call hours or shifts during nights and weekends.
“Quality of life is the biggest thing for us,” Steven Thoma said. “We didn’t want to be unhappy, basically, wherever we would go. The way your job is structured is a big part of that, so we wanted to be where we had control over the schedule.”
Dr. Mark Mulkey, president of the Mason City Clinic, said he’s found that newer recruits value mission and culture more than business details, and tend to be the best problem-solvers on a team.
But at the same time, with their desire for less time at work, “sometimes you have to recruit two to do the work of one.”
“My generation — I’m a baby boomer — took (on-call duties) every day for 12 years. The new generation doesn’t want to do that. I didn’t want to be on call every day for 12 years, but I did it,” Mulkey said. “They don’t want to give their life away to medicine. That’s a different generation from what we did.”
Andrew Perry, president and chief executive officer of McFarland Clinic in Ames, said his organization is seeing more physicians in recent years seeking part-time positions over a typical full-time role.
“We as a business have had to figure out, how do we create an environment where we can attract and attain part-time physicians?” Perry said.
So how is it done?
“It’s very hard,” he said. “I can’t say we have a solution for that. We deal with it on a one-off basis and figure out how we can meet everyone’s expectations.
“Maybe at one point you could say, ‘Well, we just won’t recruit part-time physicians,’ but in today’s world there’s not enough physicians coming out of medical school to meet the demand that’s already there, so you can’t just put those kind of rules up.”
Whether it’s salaried or a buy-in into a practice, compensation is a key conversation for physicians. With the massive amount of debt many medical school graduates face — as much as $500,000 in some cases, according to the Iowa Medical Society — aid with student loans is an appealing prospect.
Trisha Thoma came out of residency with $275,000 in student loan debt, of which the Mason City Clinic took almost half, she said.
The state of Iowa also has a loan repayment program, called Primecarre, that awards $30,000 to $50,000 to primary care medical, dental and mental health practitioners each year if they work in a health-professional shortage area, or a federally defined area of low health care accessibility, for at least two years.
Between 2001 and 2014, there were 92 recipients of a loan repayment program award, 75 of whom still practice in Iowa.
Challenges: The Cost of Recruiting
The level of compensation to attract some candidates can become a strain for some health care facilities, particularly for smaller providers in rural parts of the state.
There is an expectation being set within the competitive recruitment market to pay doctors at higher-than-ever rates, Perry said. In certain specialties, physicians can earn a higher salary “than a physician can actually produce,” he said.
MacFarland has production-based compensation for its physicians, meaning they are paid based on how many patients they see and what services or procedures they provide. But in organizations that offer salaries, Perry said compensation offered to candidates is being driven up above what that physician can do in a given time period.
“The expectations are being set really high because the market is demanding that, but they can’t produce to that level,” Perry said.
Health care officials also see a high cost up front to recruit. From the start of the candidate search to the first few months of a new physician starting a practice, Perry said it can cost McFarland Clinic between $150,000 to $250,000.
Varnum said the cost of recruitment alone at Mercy North Iowa typically is between $30,000 and $40,000.
It’s a big price tag to recruit, especially for small community hospitals, Merritt Hawkins’ Piller recognized. But he said organizations can make it up in the “downstream revenue” a physician generates — inpatient visits, radiology and anesthesia, for example.
“Your average physician generates $1.5 million (a year) in inpatient and outpatient revenue,” Piller said.
Trisha Thoma said she and her husband have felt reinforced in their choice of an Iowa clinic because individuals inside and outside the clinic have made the couple feel at home in Mason City.
“Everything we’ve experienced since we’ve been here, as far as people getting us involved in everything, has been a bonus,” Steven Thoma said.
Despite health care officials’ best efforts, candidates still switch flags — 15 percent to 20 percent of physicians move every year, according to Piller, which is easier now than ever due to more readily available opportunities nationwide.
When a doctor leaves, Piller said, it’s usually for two reasons — something was promised to them that’s not coming through or because of a lack of opportunity, such as no voice in the organization or an inability to practice medicine to the full extent of their education.
Still, there is uncertainty on how emerging changes in health care policy — such as a repeal of the Affordable Care Act or changes in Medicaid managed care — may affect the physician supply and demand in the coming years. But Iowa health care officials say they will continue a concerted effort to bring more physicians to the state.
“I don’t want us to be caught ill-prepared for the future,” said Mulkey of the Mason City Clinic.
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