Is There a Doctor in the House? Physician Recruitment and Retention in the Hudson Valley Discussion Brief #3 – Winter, 2010

C en t er f or R e s e a rch , R e g ion a l E d u c a t ion a nd O u t re a ch S t a t e u ni v er s i t y o f ne w yor k a t ne w p a lt z

Kathryn R. Reed, MHA, CMPE If we don’t pay attention to physician recruitment and retention now, there will be a price to pay in the availability and quality of medical care in our > region in the years to come.

hysicians practicing in Ulster and POrange Counties confirm what the statistics show: the Hudson Valley needs far greater success in bringing doctors here.

Kathryn Reed, MHA, CMPE, is the The need differs from place to The Demand Side Executive Director of the Catskill- Hudson Area Health Education Center place in the region: attracting located in Highland, New York. In more primary care practitioners More People Need More addition, she is Senior Program Associ- ate of the Institute for Family Health is the greatest concern in New- Doctors (Institute) and Executive Director burgh, gaps in key specialties One reason we need more of the Mid-Hudson Rural Integrated is the biggest worry in Kings- Delivery System under the auspices of doctors is, unlike many other the Institute. She brings to this position ton. Dutchess County needs regions of New York State, we over 25 years of experience as a health primary care doctors as well; have a growing population. care executive with expertise in medical practice development, management and while there are some gaps in Encouraged by technological physician recruitment. Her experience specialties, success in Dutchess changes that allow workers to also encompasses the areas of corporate development, strategic planning, public in attracting physicians has live at a greater distance from relations and marketing, grant writ- recently been greater compared their jobs, the pull of (rela- ing and development of rural health networks and integrated health delivery with Ulster and eastern Orange. tively) lower cost housing, and systems. Prior to her career in the The situation is complicated the push of the 9/11 terror- health field, Ms. Reed spent eight years further because our economy ist attacks, people have been in the legal profession as a para-legal. She possesses a Bachelor of Science is evolving and our population moving into the Hudson Valley. in Health Care Administration and a is growing, and aging. But one The U.S. Census estimates that Master of Science, Health Administra- tion and is a Certified Medical Practice thing is for sure: if we don’t pay the average growth in popula- Executive with the American College of greater attention now, there will tion for eight Hudson Valley Medical Practice Executives, a division of Medical Group Management As- be a price to pay in the avail- counties from 2000 to 2006 was sociation. Ms. Reed holds a Governor’s ability and quality of medical 4.9%.1 This compares to state- Appointment to Rural Health Council care in our region in the years of New York State and a member in wide growth during the same good standing in the National AHEC to come. period of 2.4%. Organization, National Rural Health Association and New York State As- sociation of Rural Health.

2 1 Columbia, Dutchess, Greene, Orange, Putnam, Rockland, Sullivan and Ulster Counties

Potential Impact of Table I Health Care Reform Estimated 2007 Uninsured Residents Under Age 65 in the Hudson Valley According to the New York State Department of Health, there are currently estimated to County Pop. < 65 Uninsured Pop. < 65 % Uninsured be 161,855 people under age 65 Columbia 51,788 7,983 15% without medical insurance in the Hudson Valley region. Their Dutchess 255,500 32,778 13% inability to pay constrains their Greene 41,371 5,331 13% demand for medical services. Orange 339,048 45,217 13% As we write, the particular out- Putnam 88,447 12,313 14% comes of the massive national Rockland 258,009 26,585 10% push for health care reform are still not settled. But any Sullivan 65,327 10,540 16% extension of insurance coverage Ulster 156,775 21,108 13% to many or all of the region’s Total 1,256,265 161,855 13% people who are now uninsured will almost certainly increase Source: New York State Department of Health3 their demand for both primary and specialized care. Adding the age of 60, representing of our communities at these residents to the insurance 17% of the state’s popula- certain times of the year. rolls will worsen the primary tion. By year 2015, this For example, eastern care physician shortage, trig- number is expected to Dutchess County, south gering longer waits for office grow to 3.7 million, repre- central Orange County visits and crowding emergency senting over 18% of the and much of Ulster rooms. According to the Ameri- state’s total population and County are federally can Academy of Family Physi- by year 2025, those 60 and designated as migrant cians standard physician to over will number 4.4 mil- seasonal farm worker population ratio (42:100,000), lion”.4 This means that by medically underserved the Hudson Valley will need an 2025 the older population areas. There are many additional 68 physicians to care of New York State is pro- general and mental health 2 for this new influx of patients. jected to increase by care needs prevalent 37.5%, with the last of among migrant people. Shift in Needs the baby boomers aging Migrant workers are The need for a different bal- out. In the Hudson Valley, poorly paid, unable to ance in the available medical the number of people age afford health insurance expertise in the region is also 60 or older was 219,083 and often ineligible for beginning to emerge. Consider in 2000 and is currently Medicaid, so there are two causes: estimated to be just over few providers caring for a quarter million people, this sub-population. How- • First, like the rest of the 252,349, 18% of the area’s ever, these seasonal country, the valley is population. residents are a vital graying. An older component of the region’s population places greater • Second, our region agricultural industry and demands and challenges experiences seasonal their health issues must be on the healthcare system, increases in popula- addressed. and requires physicians tion. The arrival of sea- who specialize in dealing sonal farm workers, The Supply Side with its specific medical vacationers and second issues. “New York is home homeowners doubles Physicians Are in Short Supply to 3.2 million people over the population of some At a national level, the propor-

2 Statement of A. Bruce Steinwald, Director Health Care, Testimony Before the Committee on Health, Education, Labor, and Pensions, U.S. Senate. Feb 12, 2008. GAO-08-472T, p. 14. 3 New York State Department of Health www.health.state.ny.us/prevention/prevention_agenda/access_to_health_care/estimates_of_uninsured_under_65.htm 4 Greg Olsen, MSW, Deputy Director, Division of Policy, Management and Public Information. Testimony before the New York State Assembly Standing Committee on Mental Health, Mental Retardation and Dcvelopmental Disabilities and the NYS Assembly Standing Committee on Aging on the Geriatric 3 Mental Health Act of 2005. May 16, 2008. www.aging.ny.gov/News/2008/NYSOFAOlsenTestimony.cfm Table 2 Primary and Non-Primary Care Doctors in the Hudson Valley, 2007

Total Active Number of Percent Number of Percent County Patient Care Primary Care Primary Care Non-Primary Care Non-Primary Care

Columbia 114 42 37% 72 63% Dutchess 723 222 31% 501 69% Greene 34 22 65% 12 35% Orange 831 282 34% 549 66% Putnam 244 80 33% 164 67% Rockland 890 279 31% 611 69% Sullivan 112 53 47% 59 53% Ulster 352 151 43% 200 57%

Total 3300 1131 34% 2168 66%

Source: Annual New York Physician Workforce Profile, 2008 Edition. Data only includes FTE Doctors.6

is required to serve about Table 3 2,400 people.7 In the eight- Ratio of Primary Care Doctors to People in Hudson Valley Counties, 2007 county Hudson Valley region, there are 1,131 primary care Number of Primary Ratio of Primary Care physicians in a population of County 2007 Population Care Doctors Doctors to Population 1,448,654, resulting in a ratio of 1 primary care physician Columbia 63,813 42 1519 to 1,281 persons. While this Dutchess 298,002 222 1342 bird’s eye view suggests no Greene 50,250 22 2284 shortage, the reality is that Orange 380,082 282 1348 there is a mal-distribution of physicians within the region, Putnam 101,303 80 1266 with a clustering in the more Rockland 293,644 279 1052 urban and suburban areas. In Sullivan 77,482 53 1462 fact, parts of six of these eight Ulster 183,977 151 1218 counties have been federally designated as either health Total 1,448,553 1131 1281 professional shortage areas Source: Annual New York Physician Workforce Profile, 2008 Edition. Data only includes FTE Doctors.8 (HPSA), medically underserved areas (MUA) or as having medically underserved tion of primary or general care represent one-third of the phy- populations (MUP). physicians has been expe- sician workforce. A review of riencing long term decline. Physician Profile Information For example, in Dutchess In the early 1900’s, 85% of available from the New York County a majority of the physi- all doctors were delivering State Department of Health cians are clustered in Pough- primary care. By the 1960’s, showed that about one third of keepsie and along the Route 9 this number was down to half the doctors in the region of- corridor between Poughkeepsie of all physicians in the U.S. fered primary care.5 and Fishkill. The physicians In the last decade, primary to population ratios for these care physicians have come to One primary care physician two locales are 1 to 1,060 and

5 New York State Physician Profile, January 2009. www.nydoctorprofile.com 6 Center for Health Workforce Studies, Annual New York Physician Workforce Profile, 2008 Edition. http://chws.albany.edu/download.php?id+3486748.388.2 7 According to the American Academy of Family Physicians standard cited above 4 8 Center for Health Workforce Studies, Annual New York Physician Workforce Profile, 2008 Edition. http://chws.albany.edu/download.php?id+3486748.388.2 1 to 638, respectively. How- Figure 1 ever, most of eastern Dutchess Medically Underserved Areas and Populations County is designated as hav- (MUA’s and MUP’s) ing medically underserved populations. Two rural places in which we find examples of physician mal-distribution are Pine Plains with a physician to population ratio of 0 to 2938 and Dover Plains, 0 to 5691. This problem is not limited to rural areas. Beacon has a ratio of 1 to 3,248. It is designated as having a low-income, medically underserved populace, and there are an insufficient number of physicians in the city accepting Medicaid patients. All of the counties in our region demonstrate similar primary care mal-distribution patterns, according to data provided by the Center for Health Medically Underserved Areas and Workforce Studies.9 Populations (MUA’s and MUP’s) Data Source: United States Department of Health and Human Services, Health Resources and Services Administration, Geospatial Data Warehouse These critical shortages also exist in specialty care and dentistry. A 2008 Physician Figure 2 Workforce Survey conducted by the Healthcare Association Primary Care Health Professional Shortage Area (HPSAS) of New York State (HA- NYS), reported that hospitals and health care systems had significant increases in physician shortages between 2006 and 2007 in the specialties of general surgery, orthopedics, urology and psychiatry.

In focus groups convened in Kingston and Newburgh for this Discussion Brief, physicians confirmed these findings. In response to the question: “Do you believe that there is a shortage of doctors in your area now and/or will be in the next 5 to 10 years?” participants answered in the affirma- tive. The developing need was Primary Care HPSAs viewed to be greatest in more Data Source: United States Department of Health and Human Services, Health Resources and Services Administration, Geospatial Data Warehouse rural areas like Ellenville and

9 Center for Health Workforce Studies http://chws.albany.edu/ 5 By 2020 it is projected 23,000 physicians annually will retire or die, while U.S. medical schools graduate only about 18,000 students each year.

Chart 1 The Doctor Shortage in New Hospitals and Health care systems in New York (outside of NYC) York and the Hudson Valley Reporting Physician Shortages There are two key factors that can help explain physician shortages. First, the 1997 caps 80% on the number of resident positions funded by Medicare have 70% 73% significantly reduced physician supply. Second, healthcare

60% 61% professionals themselves are 57% 57% “aging out”. 50% Nationally, we are training too 40% 44% few doctors. Physician Richard A. Cooper points out in Criti- 37% cal Care: The Coming Era of 30% Too Few Physicians that the 26% number of residency positions 20% 22% across the U.S. in 1997 was 15% capped at 1996 levels, flatten- 10% 13% ing the number of physicians entering and graduating from 0% Primary Care gen. Surgery Orthopedics urology Psychiatry post-graduate medical educa-

Source:Healthcare Association of New York State, 2008 Physician Workforce Survey, as reported by hospitals10 tion programs. There has been no change in this number 2006 2007 since, and for the past twelve years the nation has had too Margaretville. Noting that the represented while primary care few physicians to care for number of Kingston-area fam- physicians were needed. its growing population. “By ily practitioners is higher than 2020 it is projected 23,000 the national average, Kings- As a result of physician short- physicians annually will retire ton focus group participants ages, a full quarter (25%) of or die, while U.S. medical cited a shortage in specialties hospitals in New York State schools graduate only about including: OB/GYN, neuro- report reducing or eliminating 18,000 students each year.” A surgery, general surgery, GI, services or requiring patients to diminished supply of new doc- endocrinology, rheumatology, find care outside their commu- tors nationally makes it harder ophthalmology, ENT, oncology nities. A majority of hospitals for many regions throughout and gynecological oncology, (55%) experience times when the nation to meet their needs. pulmonary intensive care, their emergency departments interventional radiology, and lack coverage in particular Moreover, in our region, pediatrics. While OB/GYN specialties, thus requiring costly the barrel is likely to empty was a concern for doctors transfers of patients to facilities faster than we can fill it. As in Newburgh overall, they with proper coverage and time the general population grows thought specialties were well- lost in rendering specialty care.11 older, the cohort of doctors in

10 Access to Care in Crisis: Physicians in Short Supply. Health Care Association of New York State’s 2008 Physician Workforce Survey. November 2008. http://www.hanys.org/workforce/survey/physician/docs/2008-11_physician_workforce_survey.pdf 11 Ibid. 12 Glabman, Maureen. Primary Care Rocked by Rough Seas, Physician Executive, Jan-Feb 2009. Republished at http://findarticles.com/p/articles/mi_ 6 m0843/is_1_35/ai_n31333031/pg_2/?tag=content;co11 In our region, the barrel is likely to empty faster than we can fill it. As the general population grows older, the cohort of doctors in practice is aging even faster.

practice is aging even faster. Table 4 On average, doctors in our Average Age of Doctors and Median Age of the communities are comparatively Population in the Hudson Valley older than the population as a whole and they will be retiring County Doctor Average Age Population Median Age reasonably soon in fairly large numbers. The average age of Columbia 54 43 all active patient care physi- Dutchess 53 38 cians in New York State is Greene 53 40 fifty-one. In the Hudson Valley, it is fifty-three.13 Orange 51 35 Putnam 50 40 In the southwestern portion of Rockland 53 38 Ulster County (a particularly Sullivan 55 40 rural area), there are eight primary care providers currently Ulster 52 40 admitting patients to the Ellen- Region 53 39 ville Regional Hospital, the lo- Source: Annual New York Physician Workforce Profile, 2008 Edition. Data only includes FTE Doctors. Source for cal critical access hospital. Of Population data is U.S. Census 2006-2008 Estimates.14 those, three are over age sixty, and one is over fifty. Within the next ten years, most or all of these doctors will retire, reduce hours or close their practices Chart 2 to new patients. Moreover, the 2008 Age of Physicians in the Hudson Valley remaining three physicians in this community are within 60% an age group that, tradition- ally, will make a second or 50% third career move, creating the 50% 46% 46% possibility of a sudden criti- 40% 42% 44% 41% cal shortage of primary care 38% physicians. This scenario will 30% likely be experienced in all the 31% counties of the Hudson Valley region over the next decade as 20% 47% of all active practicing physicians in this region are 55 10% years of age or older. 0% Columbia Dutchess greene Orange Putnam Rockland sullivan ulster

Both the Kingston and New- Source: Center for Health Workforce Studies, Annual New York Physician Profile 2008 burgh physicians agreed that 55 and Over the need for doctors in our region will be more acute

13 Center for Health Workforce Studies, Annual New York Physician Workforce Profile, 2008 Edition. http://chws.albany.edu/download.php?id=3486748,388,2 14 Ibid. 7 Chart 3 HANYS reports that hospitals 2007 Increases in Physicians and Physician Need by New York State Region and health care systems outside of New York City identify 400 the current need for approximately 1,400 more physicians. 366 350 While there was a net gain

322 in the state of approximately 300 300 physicians in 2007, more than 50% of that gain was on 257 Long Island. There remains a 250 258 significant gap between suc- 200 cessful recruiting and community need, particularly in 171 regions north of Manhattan. In 150 155 148 the Hudson Valley, hospitals reported in 2007 that 148 ad- 100 ditional doctors were needed, 83 but the region was only able to 50 attract ten. 31 34 0 10 Further, New York State is not -9 retaining its medical school graduates. The Center for Western NY Rochester Central NY Northeast Hudson Valley long Island

Source: Healthcare Association of New York State, 2008 Physician Workforce Survey, as reported by hospitals15 Health Workforce Studies at SUNY Albany conducts an an- Net Gain Physicians Needed nual survey of physicians completing residencies and fellow- in the next five to ten years. tain. One doctor posited that ships in the state to document Healthcare reform may, and an locally “MSO’s (Medical Ser- whether or not training efforts aging population will, increase vice Organizations) will drive are consistent with the state’s demand at the same time that the thing.” Moreover, he com- physicians needs. This survey area doctors are aging out of mented, “Where we sit feder- reveals that fewer new doc- the profession and there is ally and locally impacts us.” tors are staying in New York an insufficient influx of new Another physician believed, after completing training. In physicians. In Kingston, one “If [the federal government] 2007, while 80% of graduates doctor estimated, “There will comes through with a unified who grew up in and attended be a four-fold increase in health plan that sets priorities, a medical school in the state utilization and no manpower.” reworks reimbursements, and reported plans to practice here, One Newburgh doctor pre- does social engineering, we a large majority of students dicted Physicians Assistants won’t have a shortage,” and originally from outside the and Nurse Practitioners would “there is potential for drastic state are leaving after complet- replace doctors in the future, if change.” ing their residencies. In 2008, not by design then by neces- 45% indicated they planned sity. New York has well-document- to remain in New York, down ed, long-term difficulties in from 53% in 2001.16 Yet, at the same time as these recruiting and retaining physi- physicians believe it is certain cians for hospitals, long-term Difficulties in Physician the future will be very chal- care facilities and outpatient Recruitment lenging, several doctors in the health care organizations and Kingston focus group thought practices throughout the state, Why do we have these short- it important to note that the particularly in rural areas. The ages? What, if any, special future also remains very uncer- Hudson Valley is no exception. factors are operating in the

15 Access to Care in Crisis: Physicians in Short Supply. Health Care Association of New York State’s 2008 Physician Workforce Survey. November 2008. http://www.hanys.org/workforce/survey/physician/docs/2008-11_physician_workforce_survey.pdf. Hudson Valley is defined here as Dutchess, Ulster, Putnam, Orange, Westchester and Rockland Counties. 16 Armstrong DP, Moore J, and Forte GJ. Fewer New Physicians Staying in New York after Completing Training: A Resident Exit Survey Summary Brief. Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany. December 2008. http://chws.albany.edu/download. 8 php?id=357854,371,2 Competition for patients with other regions is not just a medical issue; it is a community issue, as well.

Hudson Valley? And what public medical school tuition ance, and cash flow for staff should we do about them to and fees increased by 133% and two physician salaries and assure continuity in the range over the same time period.18 benefits during the anticipated and quality of healthcare that It is estimated that the cost two-year growth period before the region’s people have come of becoming a doctor - from the practice was expected to to expect, now and into the the date of entry to medical be self-sustaining. Though future? school to the point of entry into specialty practices pay more, practice - is now $180,000. specialty practice start-ups When asked, “What do you The average debt of a graduat- costs can be significantly see as the top three challenges ing medical student in 2008 higher, based on the need for to the recruitment and reten- was $154,600, an 11% increase advanced technologies related tion of doctors to this area now over the previous year. Many to the medical discipline. and in five to ten years?” area students defer paying their doctors frequently mentioned loans until they have com- Another significant barrier is a fundamentals: money, lifestyle pleted their residency program, lack of referrals for new physi- and family. In large measure which due to the accumulation cians entering into practice. these observations conform of interest during the period of “Without readymade referral to the findings of the Albany deferment, increases the aver- patterns it is that much more Center for Health Workforce age debt to $180,000.19 difficult to sustain a practice, Survey, in which the primary and really thrive,” one Kings- reasons given by recent gradu- Focus group participants ton doctor stated. In addition, ates for leaving the state was reported that the need to repay and especially because of the to be near family, the cost of loans and meet startup costs proximity to world-class health living here and offers of better was a factor young physicians care elsewhere, patients choose jobs and/or higher salaries often cited when explaining to go outside the region for outside the state.17 why they choose other, more specialty care. Medical centers lucrative regions in which to in New York City, Albany and Financial Factors practice. The words of one even Boston are near enough The major financial factors that Newburgh doctor confirmed for patients to take advantage impact physician recruitment that primary care is particu- of them, but not close enough are the high cost of medical larly hard hit by the financial for local specialists to draw education with its enormous pressures on new doctors: “It’s upon for support. “There is a concomitant educational debt, because of money. They go 51% out-migration of patients the cost of establishing a into specialties to make more for specialty care,” one physi- practice and meeting cash flow money.” The cost to establish a cian asserted, “and this in areas needs in the first two years, the solo primary care practice and where we do offer services.” differential burden of medical covering cash flow for the first malpractice insurance costs two years is about $350,000. Competition for patients with and disparities in reimburse- To cite one specific case, a other regions is not just a ment rates for services from newly established primary care medical issue; it is a commu- government and insurance practice in the Hudson Val- nity issue, as well. “How can companies. ley borrowed approximately doctors strengthen the commu- $500,000 to cover the purchase nity and how can the commu- Private medical school tuition of equipment and furnishings, nity strengthen doctors?” one and fees increased by 50% be- rent, supplies, medical liability, Kingston doctor asked. At least tween 1984 and 2004. Median property and business insur- some out-migration of patients

17 Ibid. 18 Jolly, Paul. Midical School Tuition and Young Physician Indebtedness. Association of American Medical Colleges, March 23, 2004. https://services.aamc. org/publications/showfile.cfm?file=version21.pdf&prd_id=102&prv_id=113 19 Medical School Tuition and Young Physician Indebtedness, An Update to the 2004 Report. Association of American Medical Colleges, October 2007. https://services.aamc.org/publications/showfile.cfm?file=version103.pdf&prd_id=212&prv_id=256&pdf_id=103 9 One Newburgh area doctor put it succinctly: “Five miles away, across the bridge in Beacon, they pay 40% less in malpractice premiums and get higher reimbursements.”

was attributed to specialists County is grouped with rural one in Ellenville. It’s all about who refuse Medicaid patients. counties, such as Ulster, at a the economics of the area.” In Newburgh, one physician much lower rate of reimburse- felt there was not enough pa- ment compared to Manhattan. Quality of Life Issues tient volume for some sub-spe- One Newburgh area doctor put Then there are the quality of cialties. Another said, “Patients it succinctly: “Five miles away, life issues: social isolation, are often diagnosed here but go across the bridge in Beacon, lack of opportunity to consult to the city for a second opinion they pay 40% less in malprac- with professional peers, limited and don’t come back. How tice premiums and get higher availability of after-hours do you compete with Sloan- reimbursements.” This creates coverage and the predispo- Kettering?” a clear financial disincentive sition for physicians now for primary care physicians entering the workforce to work The economics of practicing to locate a practice in eastern fewer hours. It is becoming medicine in the Hudson Valley Orange County. increasingly difficult to retain also involve curious and illogi- physicians in smaller, rural cal disparities in malpractice Additionally, reimbursement communities when the compet- insurance costs and patient rates from private insurers dif- ing alternative includes the services reimbursement rates. fer from company to company consultative relationships and The high cost of malpractice and practice to practice. A phy- amenities of medical centers insurance - and the disparity in sician joining a larger practice in larger, suburban and urban the size of premiums between with greater bargaining power locations. Some doctors remain up- and downstate – is a front is likely to be able to obtain interested in research opportu- burner issue in New York that higher rates per patient, while nities after entering practice, has a special impact in our sharing – and thus lowering which are usually more avail- region. Orange County is des- – costs of doing business. In able in larger places. Cover- ignated a metropolitan service contrast, physicians in small age by colleagues needs to be area, and therefore grouped practices have little bargaining available to provide a respite with Manhattan and suburban power. This is a clear disincen- from the daily responsibility of counties in the determination tive for doctors, especially in patient care: no one wants to of medical malpractice insur- specialties with the great short- be on call twenty-four hours a ance premiums. As a result, a ages, to come to places without day, seven days a week. primary care physician practic- larger practices or groups. ing in Orange County might Compared with doctors in the pay $10,000 more per year General economic conditions past, today’s medical school for medical liability insurance are also a factor. One doctor graduates do not expect to compared to colleagues located vividly recalled the effect of an work very long hours. On aver- in the adjacent counties of economic trauma now a decade age, in New York, new primary Ulster or Dutchess. However, and a half old: the closing of care physicians expect to work when managed care companies the Kingston IBM plant in between 40 and 46 hours per and Medicaid/Medicare com- 1994. “Recruiting suffered. I week, far fewer than their missions determine allow- have practices in Hyde Park, predecessors.20 As a result, it is able fee for service schedules Kingston, New Paltz and El- necessary to recruit more than and rates of reimbursement lenville. I could recruit twenty one newly minted physician for medical services, Orange doctors to Hyde Park for every for each old school doctor he

20 Residency Training Outcomes by Specialty in 2007 for New York: A Summary of Responses to the 2007 New York Resident Exit Survey, Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany. March 2008. 10 or she replaces to meet the practitioner in his group office: have to stay in the community same level of health services “He leaves at 4:30 every day. for the long term once they demands. He wants a nice lifestyle. The are hired. In Newburgh, where first question asked when we proximity to New York City Physicians in our Kingston are trying to find a new col- was considered an asset to and Newburgh focus groups league is, ‘How often am I on recruitment and retention and viewed overwork and taxing call?’” area schools were not consid- call schedules as a serious ered to be adversely perceived, deterrent to recruitment and In Kingston, family consider- desired proximity to family retention. “People now want 9 ations were also identified as a who may live in another state to 5,” said one Kingston physi- deterrent to the recruitment and or country was cited as a rea- cian. “New doctors coming retention of doctors to the area. son for attrition: “When they up are not entrepreneurial, not The perception, or mispercep- have children, they want to be doing the professional thing. tion, of limited career opportu- near family,” one focus group They want larger groups for nities for spouses, or that local participant said. support.” A Newburgh doctor public schools are sub-par, described a young, unmarried were concerns. Also, doctors

Terms and Organizations, Otsego, Putnam, Rockland, Scho- vened, one in Kingston, Ulster Methods and Sources harie, Sullivan and Ulster. There County, designated as rural by are 62 HPSAs and 58 MUAs in the New York State Department An Area Health Education this region. of Health, and one in New- Center (AHEC) is a not- burgh, Orange County, which for-profit organization that Statistical and demographic data is predominately urban and focuses on health workforce sources for this report include: suburban. A total of nine physi- development in medically • New York State AHEC cians participated including underserved neighborhoods. Data Warehouse primary care doctors and spe- Health Professional Short- • Center for Health Work force cialists representing cardiology, age Areas (HPSA). A federal Studies at the University urology, orthopedic surgery, designation given to localities of Albany radiology and internal medi- with a population to physician • New York State Office of Aging cine. Meetings were conducted ratio of 2000 to 1 or greater, • U.S. Census Bureau by a professional facilitator, are broken down into primary • Primary Care Coalition of and focused upon: whether the care, mental health and dental New York State participants believed there was care disciplines and are as- • New York State Department a physician shortage in the area signed to both urban and rural of Health and Office of Rural and why; the top three chal- communities. Health lenges to recruitment and reten- Medical Underserved Areas tion of healthcare providers (MUA) are federally desig- These resources provided data now and over the next decade; nated based on an index of for analysis at national, state, and identification of success- poverty level, infant mortal- regional, county and community ful recruitment strategies that ity rate, population over age levels. Anecdotal evidence was might serve as a model for now sixty-five and the ratio of also incorporated to enliven and and in the future. Additionally, population to primary care enrich the analysis. supplementary data and ma- physicians. Catskill Hudson terials were gained from field AHEC covers eleven coun- Focus Groups. Two focus groups interviews and compiled by the ties: Columbia, Delaware, consisting of healthcare adminis- CRREO staff. Dutchess, Greene, Orange, trators and physicians were con-

11 “Community health centers are a big draw: you’re salaried, have no administrative responsibilities - no headaches. If the contract allows them to stay, they’ll stay.”

Local and Statewide facilitating and recruitment up to 18 months), and its limi- Solutions consultant. tation of eligibility for support to physicians within five-years In 2007, Catskill Hudson Simultaneous with the AHEC of post-residency. AHEC engaged commu- effort, early in the governor- nity leaders in developing a ship of Elliot Spitzer, New In March 2009, Catskill community-specific physician York State sought an approach Hudson AHEC secured a recruitment and retention pro- to dealing with physician grant from the New York State gram. A feasibility study was shortages, especially in rural Department of Health under conducted across the Catskill areas. In 2008, the Doctors the Health Efficiencies and Hudson AHEC’s eleven-county Across New York program be- Accountability Law for New region. It included thirty-eight gan to provide financial incen- Yorkers (HEAL NY) program individual interviews with tives in the form of educational to implement HealthMatch™ community leaders represent- loan forgiveness and practice as a pilot project with the Town ing healthcare, local govern- support. The loan forgiveness of Wawarsing, the Village of ment, economic development program grants up to $150,000 Ellenville and surrounding and civic organizations. There to physicians who practice in communities. Funding at the was a nearly unanimous as- an area of need in New York level of $200,000 was granted sessment that physician short- State in exchange for a five- over a two-year cycle, with ages were at a critical level and year commitment to remain in the goal of placing at least one a community-specific, collab- the practice setting. Physicians primary care provider within orative approach to physician receive incremental payments the targeted service area. recruitment was a sound strat- over this five-year period, and Partnering with the town, the egy for success. As a result, the proportion of the total for- village, Ellenville Regional HealthMatch™, a physician re- giveness increases each year as Hospital and the Institute for cruitment and retention service an incentive to fulfill the time Family Health, the project of Catskill Hudson AHEC was commitment. Additionally, at this writing is in its tenth developed as a collaborative the practice support program month of a two-year imple- effort to bring the commitment provides up to $100,000 over a mentation period. To date, of healthcare, business and two-year period to established it has been successful in the civic leaders together in order practices that are hiring new establishment of a Community to provide increased local physicians. The intent is to Development Council, obtain- access to quality healthcare. assist with the cash flow of ing an initial financial com- Incorporating HealthMatch™ the practice during the start-up mitment for a revolving loan into the larger community phase. Coupled with communi- and receiving endorsement of economic development plan, ty-based recruitment incentive the HealthMatch™ program the community implements pools, the idea was to provide from the Catskill Watershed recruitment incentive pro- competitive leveraging to Corporation and Ulster County grams, assumes the role as the attract health professionals to Economic Development “first impression” team and rural areas in need. Two limita- Agency. Simultaneous with assists with capital financing tions are the short six-month this initial fund development programs and in-kind services time frame that the program phase, Catskill Hudson AHEC toward practice support with allows to recruit a physician launched a direct mailing Catskill Hudson AHEC as the (typically this process can take recruitment campaign to

12 physicians and primary care munity health center as part of technology. More doctors will residents in training across a loan-forgiveness program, go there.” And another New- the United States. To date, said that a number of doctors burgh doctor elaborated, one family physician has been in her program were still in recruited to a position at the the area: “Community health “In a large group, you Eastern Correctional Facility in centers are a big draw: you’re have turn-key doctoring. Napanoch as a result of these salaried, have no administra- The hospital [St. Luke’s collaborative efforts between tive responsibilities - no head- in Newburgh] is trying to key stakeholders within the aches. If the contract allows get people together with community and Catskill Hud- them to stay, they’ll stay.” common goals. Older son AHEC. doctors don’t want to Hospitals have a crucial role to change. Younger doctors What to Do? play in physician recruitment will group in order to have and retention. By hiring hospi- better quality of life. They Physicians in Newburgh and talists, they alleviate in-patient could collaborate with older Kingston offered a range responsibilities of other physi- doctors but older doctors of ideas for increasing our cians, reducing the constant don’t want to spend time region’s prospects of success pressures put upon them. By and money on the cusp in recruiting additional doc- speeding up the credentialing of retirement.” tors to practice here. General of new doctors, a process that economic development efforts can take six months to a year, The relative success of the that build the local economy they help fully integrate doc- Health Quest system is not make the community more tors into the community. And just a matter of size. Integrated attractive to doctors, as they hospitals can establish shared with its three hospitals - Vas- do for their service businesses. call systems that unites special- sar Brothers Medical Center, Tax abatements are needed for ties. Eastern Orange County Putnam Medical Center and new practices, as is county and physicians were encouraged by Northern Dutchess Hospitals - community underwriting for the priority given to support- this system includes a medical much needed specialties like ing physician recruitment by group with offices throughout pediatrics. Local universities the leadership of the St. Luke’s its region that offers primary can help in retaining doctors Cornwall Hospital and its ef- and specialty care, a model by providing academic support forts to retain patients in the that generates referrals for for clinical studies and provid- region. its specialists and allows it to ing research and development offer working conditions at- opportunities. Stronger con- There was a consensus among tractive to new doctors. Critics nections with medical resi- the doctors we spoke with that worry, however, that physi- dency and fellowship programs larger groups like Medical cians working as employees in Albany and Westchester Service Organizations (MSOs) in systems like Health Quest’s are essential: “Establish their and Independent Practice may be too often constrained connections early so they know Associations (IPAs) were the by fiscal considerations, that the area, and will stay.” wave of the future. Health the physician-patient relation- Quest was cited as a boon to ship might be attenuated and Loan forgiveness programs recruitment and retention in that the productivity of doctors were suggested, especially Dutchess County. In New- who are not practice-owners incentives that offer incremen- burgh, one doctor talked about might diminish. tal annual increases to discour- the establishment of Crystal age two-year stints. Again the Run in Middletown: “Ten Nevertheless, Health Quest principle, “If people establish years ago there were ten doc- brings great strengths to the roots, they don’t leave.” One tors, now there are 106. They task of physician recruit- doctor in Newburgh, who came have a good call schedule, ment. It is among the most to the area to work for a com- electronic medical records and financially successful medical

13 providers in New York State, to market conditions. The and therefore is able to devote future supply of primary care serious resources to physician physicians is dependent on the recruitment and offer doctors continued attractiveness of this secure, attractive, long-term career path, access to it (linked opportunities. Based upon to financial support for medical detailed proprietary research education) and incentives for done to determine the needs entering these particular areas of the communities it serves, of practice – all of which are in Health Quest’s recruitment turn connected overall to na- efforts are expert, focused, tional health care reform. The proactive and continuous, and decision to extend the Doctors are integrated, as well, with a Across New York Program, systematic effort at retention needed even more so in these after recruitment. They also very difficult fiscal times, will collaborate with other upstate, be made in Albany. Regional in-house hospital physician re- leaders must continue to lobby cruitment efforts. In Kingston, hard to remove damaging, ir- where Kingston and Benedic- rational geographically-based tine Hospitals have formed an disparities in reimbursement alliance, doctors saw promise: for primary care physicians and specialists in parts of the “Medicine is dynamic Hudson Valley, but again the right now. The hospitals’ ultimate decisions are at the alignment has changed the national and state levels. scope of how we do things. It is in its infancy and it is One idea that we can act a huge cultural shift, even upon locally is intriguing, an for doctors who have idea that might bring people previously served at both struggling with two seemingly hospitals. It is an opportu- distinct problems into the same nity to forge a new system room to help find solutions and, at the same time, there to both. While hospitals and is a national debate which medical practices work to at- promises to change things tract doctors - the supply side, as well. It’s a paradigm local government leaders in the shift that coincides with region struggle to control the a national shift. We can’t rapidly rising costs of health squander this opportunity.” insurance for their workers - the demand side. Local Conclusion government has enormous health care buying power. The Much of our region’s future premiums paid to insure public success in physician recruit- employees in Ulster County ment will be based upon a alone in 2008 approached $100 combination of decisions made million. Could this buying at the state and national levels, power be better directed to as- and how markets shape and sure the persistence of quality respond to them. Models of care, delivered in our region by medical practice in the region doctors who may be attracted are already shifting and will to live and work here? The continue to shift in response question is worth pursuing. v

14 Citation The Center for Research, SUNY New Paltz Reed, Kathryn (2010) Is Regional Education and The State University of New there a Doctor in the House? Outreach (CRREO) con- York at New Paltz was named Physician Recruitment and ducts studies on topics of re- “Hottest Small State School” Retention in the Hudson Valley gional interest; brings visibility in the 2008 Kaplan/News- (CRREO Discussion Brief 3, and focus to these matters; week How To Get Into Col- Winter 2010). New Paltz, NY: fosters communities working leges Guide, which identifies SUNY New Paltz Center for together to better serve citi- America’s 25 Hottest Schools. Research, Regional Education zenry; and advances the public The guide features schools and Outreach. interest in our region. that all offer top academic programs and are making their Comment mark in the competitive world To comment, write to CRREO of higher education. New Paltz at [email protected]. is a highly selective college of about 8,000 undergraduate Thanks and graduate students located The author wishes to thank in the Mid-Hudson Valley Janis Benincasa, Gerald between New York City and Benjamin, Joshua Simons, Albany. Degrees are offered in KT Tobin Flusser and Fredda the liberal arts and sciences, Merzon for their assistance which serve as a core for pro- with various aspects of this fessional programs in the fine project. and performing arts, education, healthcare, business and engineering.

15 860350

CRREO 1 Hawk Drive New Paltz, NY 12561

, in ; brings working working together to to these matters; independent research independent

regional regional interest across across the Hudson Valley advance the public interest for-profits for-profits CRREO:conducts on topics of visibility and focus fosters communities to better serve the citizenry; and seeks to region. our Independently and Independently in with collaboration local business and governments, not-