Retention and Recruitment Issues Brock Slabach, FACHE Sr. Vice-President National Rural Health Association bslabach@nrh

1. Retention and Recruitment Issues Brock Slabach, FACHE Sr. Vice-PresidentNational Rural Health Associationbslabach@nrharural.org 816-756-3140 x14

2. NRHA Mission The National Rural Health Association is a national membership organization with more than 18,000 members whose mission is to provide leadership on rural issues through advocacy, communications, education and research.

3. Improving the health of the 62 million who call rural America home. NRHA is non-profit and non-partisan.

4. Why rural is different… 1) The challenges of rural 2) The importance of rural health care (both for rural Americans and the rural economy)

5. Operation Patient Access • Health cannot be improved without access to health care. • Access is remains the gravest concern for rural America. • Operation Patient Access is Critical.

6. State ofHealth Care in Rural America • 25% of population over 90% of landmass; • combination of factors make health care disparities much more acute in rural America; • economic, cultural, educational, demographic factors all play importance rolls; • great distances mean lack of preventative and follow-up care ( more chronic illness – heart disease, diabetes) • overall population is older, requiring more intensive care • additionally - - rural mortality is 50% higher than the overall U.S. rate • death rates for children - - 20% higher • sedentary lifestyle is prevalent in rural America • economic factors, low insurance (fewer employers), high poverty • more dependency on Medicare and Medicaid • inappropriate and unfair federal reimbursement rates • 50 million Americans live in HPSA – vast majority of those areas are in rural America • Provider shortages: 25% of population lives in rural America, yet only 9% of physicians practice in rural America.

7. The Workforce Shortage Crisis… In 20 years, 20% of population will be over 65 years old. At the same time, physician shortages are predicted to be over 200,000 - - meaning some 84 million could go without care. Number of graduates has remained virtually flat for 25 years. Tuition has skyrocketed - - 750% (private) and 900% (public). One-third of physicians are 55 or older and soon will retire. More than half of rural general surgeons are older than 50, and a wave of retirements is expected in the coming decade. Decline in the numbers of Residents completing General Surgery programs Physician shortages in rural America is one a major intractable health policy problem of the last century…crisis is inevitable. Recruitment and retention problems persist - - yet 50 million Americans live in areas where shortages exist.

8. The General Surgeon Crisis • In 1994, there were 7.1 general surgeons per 100,000 people. Today there are five per 100,000. • In rural America the problem is much graver. • In rural America -- some places have only half as many surgeons per capita as cities -- that the problem is most acute. And it's likely to get worse. • Population to support one General Surgeon ranges from 10,362 (GEMENAC) to 16,471 (Kaiser)

9. Crisis Dimensions – the implications • Without general surgeon battle, primary care is crippled - - e.g., Family practitioners cannot deliver babies, emergency rooms cannot take trauma cases, and most internists will not do complicated procedures such as colonoscopies. • Only 9,334 of the 211,908 rural physicians are general surgeons.

10. Rural Challenges/Disparities • Geographic • Cultural • Payment/Reimbursement • Poverty/Sociological • Lifestyle • Aging (high chronic disease) • Employment (hazards) • Accidents • April 2008 Harvard study: Life expectancy actually declined in certain rural populations (Appalachia/Deep South)

11. Heath care and the rural economy • Over the last decade, cities and towns across nation lost manufacturing jobs, but gained heath care jobs. • Last year the manufacturing industry lost 310,000 and health care industry gained 363,000. • Rural manufacturing jobs declined at double the rate of urban manufacturing jobs. • Education and health care are the largest rural employers and added the most jobs to the rural economy in 2007.

12. Recession Hits Rural America • In December alone, 282,000 were lost in the nation’s 2,048 rural counties. • December numbers indicate a 29% increase in job losses. • Uninsured and Under-insured is rising at a faster rate in rural America than urban America. • Healthcare is the fastest growing segment of rural economy.

13. Healthcare Critical to Rural Economy • Each rural physician generates 23 jobs in the local rural economy • in most rural communities hospitals are the largest or second largest employer • Health care often represent up to 20 percent of a rural community's employment and income.

14. Recruention*Plan Ahead • Recruitment cycle is 18-24 months • Timing, Timing, Timing • 2008 Survey: --82% of Residents began searches over one year prior to graduation --78% desired salary w/ production bonus * Tim Skinner, 3RNet

15. Surgeons Top 10 Reasons for Changing Jobs • Higher Compensation 38% • Better Work Environment 25% • Other 17% • Better Community 13% • Malpractice in State 7%

16. Surgeons Top 3 Frustrations • Reimbursement Issues • Medical Liability Issues • Administrative and Business Agendas that interfere w/ Clinical Decisions Recruitment Strategy must address these factors.

17. Sourcing General Surgeons • Networking 44% • Other 23% • Recruiters 18% • Internet Search 11% • Journal (print) 4% Other: Military Commitment, Professional Society, locums to permanent Source: Locumtenens.com

18. Rural Recruitment Resource • 3RNet • Partly funded by Office Rural Health Policy (ORHP) • www.3rnet.org/ • 1-800-787-2512 • NRHA Partner for Rural Workforce

19. Solutions for Change • Include general surgeons in National Health Service Corps - - 30 year success. • Expand Residency Programs • Create Equity in Reimbursements • Creative Tax Incentives • Improve Telemedicine Capabilities

20. Questions?