Study Shows Shortages in Key Specialties, Difficulty in Recruitment

WALTHAM — The Mass. Medical Society (MMS) recently released its annual study of the state’s physician workforce, once again showing shortages in several specialties and continuing difficulty in recruitment and retention of physicians, especially at community hospitals and in areas outside of Boston.

The study also noted some positive trends: more physicians say they are familiar with payment-reform initiatives such as accountable-care organizations and global payments, and more indicated a willingness to participate in one or both of these new models of care. Additionally, slightly fewer physicians said they have altered or limited the scope of their practice for fear of being sued.

The 2012 Physician Workforce Study is the Society’s 11th annual comprehensive look at the physician workforce in Massachusetts and includes surveys of practicing physicians, department chiefs of teaching hospitals, and medical staff presidents of community hospitals. Among the topics surveyed were the labor supply of physicians; recruitment and retention; satisfaction with the profession and practice environment; willingness to participate in global payment programs and accountable-care organizations; opinions of the U.S. health care system; and the impact of professional-liability concerns on the practice of medicine.

“This year’s study has mixed results,” said Dr. Richard Aghababian, president of the MMS. “We still have shortages of physicians in key specialties, especially primary care, and, despite some positive trends, physician recruitment is problematic, particularly for community hospitals.

“Yet we also see some positives,” he continued, “with more physicians willing to participate in accountable-care organizations and global payments, and that bodes well as health reform continues to evolve.”

Aghababian also cautioned that physicians face new challenges ahead. “The payment-reform bill signed in August has many provisions pertaining to physicians and the practice of medicine. While we are heartened by the law’s provisions for medical-liability reforms and preventive care, just how the law will affect our physician workforce and to what degree is unknown at this time. It is something we will be watching carefully, particularly as it affects physician practices and patient care. ”

Following are some key findings from the 2012 Workforce Study:

Specialties in Short Supply

The medical society’s 2012 analysis found seven of 18 specialties, one fewer than in 2011, to be in critical or severe shortages: family medicine, internal medicine, general surgery, neurosurgery, dermatology, psychiatry, and urology.

Four specialties — internal medicine, psychiatry, urology, and neurosurgery — met the criteria to be classified as facing ’critical’ shortages. Three were classified as ’severe’ — family medicine, dermatology, and general surgery.

The 2012 study records both family medicine and internal medicine with shortages for the seventh consecutive year.

Year-to-year Trends

Of the five non-primary-care specialties in short supply, four are seeing particularly tight labor markets. Urology is experiencing six consecutive years of shortages, and dermatology has seen five consecutive years. Psychiatry has been in short supply for six of the last seven years, and neurosurgery, the specialty having shortages more frequently than any other, has been in short supply in nine of the 11 years of the society’s studies.

A trend analysis over a five-year period (2008-12) shows that 10 specialties have been in short supply in at least three of those five years: family medicine, internal medicine, vascular surgery, urology, dermatology, neurology, psychiatry, general surgery, orthopedics, and neurosurgery.

Recruitment and Retention

The 2012 Physician Workforce Study found mixed results regarding the recruitment and retention of physicians in the state. While 2012 marked the fifth consecutive year that saw a decrease in both the recruiting time to hire physicians and in the number of physicians reporting difficulty in retaining physician staff, recruitment remains difficult for those seven specialties seeing critical and severe shortages and in areas outside of Boston, and it remains particularly hard for community hospitals.

More than 94{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of community hospitals report significant difficulty in filling vacancies (compared to 7.3{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of teaching hospitals and 22{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of practicing physicians) and 87{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} report increased recruiting time (compared to 30{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of teaching hospitals and 39{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of practicing physicians). As a result, 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of community hospitals report that it has been necessary to alter services, and 87{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} report it has been necessary to adjust staffing.

Among the reasons reported by community hospitals for this disparity are that a limited number of physicians are interested in working for a small community hospital, Massachusetts offers lower compensation and has a higher cost of living than other states, and smaller hospitals are often unable to offer competitive salaries. The specialties community hospitals find the most difficult to hire include neurosurgery, dermatology, cardiology, vascular surgery, orthopedic surgery, obstetrics and gynecology, and the primary-care specialties of internal medicine and family practice.

Regional Labor Markets

With few exceptions, recruitment and retention in the areas outside of Boston are even more difficult. For the four labor markets of Worcester, Springfield, New Bedford/Barnstable, and Pittsfield/Western Mass., physicians indicated it was more difficult to fill vacancies, more difficult to retain staff, and took more time to recruit than last year. The needs to alter services and adjust staffing were also greater in the regional markets.

Physician Satisfaction Low

For the second year in a row, the percentage of physicians (40{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) who say they are satisfied with the practice environment in Massachusetts equals the percentage (40{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) who say they are dissatisfied, though both percentages showed decreases from the previous year (42{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}, 42{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}).

MMS officials say that the fact that fewer than half of all physicians are satisfied with the practice environment reflects the findings of the annual MMS Physician Practice Environment Index, a statistical compilation of nine selected factors that influence the overall practice climate for physicians in the state. While the index rose fractionally (0.4{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) in 2011, it was only the third increase in the index in the 20 years that it has been compiled.

Care vs. Administration

Most physicians (78{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) find their careers rewarding, but more than half (53{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) are dissatisfied with the division between patient care and administrative tasks. This is especially pronounced among primary-care physicians (family medicine, internal medicine); with 62{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} expressing dissatisfaction with the tradeoff between patient care and the administrative tasks they are required to perform.

Views of Payment Reforms

For the second year in row, the study asked physicians about payment-reform initiatives being undertaken in the Commonwealth, specifically global payments and accountable-care organizations (ACOs). Responses to questions in 2012 showed an increased familiarity with both global payments and ACOs and an increased willingness to participate in either or both.

Global Payment Systems

Familiarity with global payments is high, with 65{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of physicians saying they were familiar with global payments, up from 57{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} last year. Also, 48.7{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} (up from 42{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} last year) said they were likely, and 51.3{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} (down from 58{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) said they were not likely to participate in a voluntary global payment system.

Employed physicians (at a 61.6{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} rate) are more likely to participate in global payments than self-employed physicians (43.4{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}).

Findings on ACOs

Familiarity with ACOs is high, with 73.5{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of physicians saying they were familiar with ACOs, an increase from 58{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} last year. Sixty percent said they were likely, and 40{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} said they were not likely, to participate in a voluntary ACO.

Pediatricians (72.7{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) and primary-care physicians (71.2{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) are more likely to participate voluntarily in an ACO than specialists (60.9{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}).

Physicians working in practices of 250 or more physicians (84.3{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), in practices between 26-100 physicians (70.8{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), and in practices of 11-25 physicians (68.9{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) are more likely to participate in a voluntary ACO than those working in smaller or solo practices.

Impact of Liability

The 2012 study again found that professional liability (medical-malpractice concerns) and the fear of being sued continue to have a substantial negative influence on physicians and the practice of medicine, though somewhat less than in previous years. This finding is consistent with the society’s previous workforce studies and its Investigation of Defensive Medicine in Massachusetts of November 2008, which showed that the fear of being sued is a serious burden on health care. Among the findings from the 2012 Workforce Study:

41{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of physicians said they have altered or limited the scope of their practice because of the fear of being sued — 5{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} fewer than in each of the last three years.
More than 40{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of physicians in 12 specialties said they have altered or limited their practice because of the fear of being sued: orthopedics (63{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), urology (63{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), neurosurgery (60{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), emergency medicine (57{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), family medicine (50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), obstetrics/gynecology (48{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), neurology (44{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), general surgery (43{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), internal medicine (42{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), cardiology (41{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), gastroenterology (40{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), and radiology (40{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}).
The Medical Society points out that this research was gathered before the new health care payment reform law was signed in August. The law includes reforms to the state’s medical-liability system, including provisions for a six-month resolution period that affords the time to go through a disclosure, apology, and offer process with sharing of all pertinent medical records by the patient, full disclosure by providers, and for statements of apology by providers to be inadmissible in court.