1

West Virginia’s Primary Primary

Care Workforce Pipeline T i i Training Programs

Presented to “Presented to “Strengthening the Health Care Safety-Net Workforce Though Cooperation, Planning, and Policy”

July 20, 2009NACHC-NCSL-ASTHO-NASHP

Convention CenterPhiladelphia, PA

Hilda R. Heady, MSWHilda R. Heady, MSWAssociate Vice President for Rural HealthAssociate Vice President for Rural HealthRobert C. Byrd Health Sciences Center of Robert C. Byrd Health Sciences Center of

West Virginia UniversityWest Virginia UniversityExecutive Director WV Rural Health EducationExecutive Director WV Rural Health Education

Partnerships/AHECPartnerships/AHEC

2

The MessageThe Message

State policymakers, educational State policymakers, educational institutions, and community leaders institutions, and community leaders working as a partnership team can make working as a partnership team can make a difference.a difference.

There is no ONE silver bullet, therefore There is no ONE silver bullet, therefore strategies appropriate for states and strategies appropriate for states and regions must be blended into a full regions must be blended into a full pipeline of programspipeline of programspipeline of programs.pipeline of programs.

Outcomes should be directly linked to Outcomes should be directly linked to health status, program elements, and health status, program elements, and best practices.best practices.

Synergy and Success requireSynergy and Success require

VisionVision

LeadershipLeadership

The social and political The social and political will to do the right thingwill to do the right thing

3

Experience and EvidenceExperience and EvidenceRural Training Tracks for professional Rural Training Tracks for professional students and graduate residentsstudents and graduate residents

Significant portion of training in rural Significant portion of training in rural communitiescommunities

Financial incentives in training with or Financial incentives in training with or without service obligations without service obligations

Experience and Evidence supportsExperience and Evidence supportsEducational Strategies that work:Educational Strategies that work:

Pipeline programs ith r ral foc s and Pipeline programs ith r ral foc s and Pipeline programs with rural focus and Pipeline programs with rural focus and contentcontent

Recruiting rural people into programsRecruiting rural people into programs

Strategic admissions’ strategies (% of Strategic admissions’ strategies (% of class, reserved slots, rural preferences)class, reserved slots, rural preferences)

4

Experience and EvidenceExperience and Evidence

Community lead initiativesCommunity lead initiativesFi i l i ti f d t Fi i l i ti f d t •• Financial incentives from and to Financial incentives from and to CommunitiesCommunities

•• Focus on health status of communitiesFocus on health status of communities•• Strategies that improve community’s Strategies that improve community’s

ability to recruit and retain healthcare ability to recruit and retain healthcare ability to recruit and retain healthcare ability to recruit and retain healthcare providersproviders

•• Community economic developmentCommunity economic development

Rural and UnderservedRural and UnderservedHealth Professions Workforce Health Professions Workforce

DevelopmentDevelopment

Know the principles and strategies Know the principles and strategies and piece them togetherand piece them together

TrainPay

SupportRecruit Rural

them

y

do it!

Learners

Require

5

Th W VTh W VThe West Virginia The West Virginia ExperienceExperience

HistoryHistory

Election of an “education” Governor Election of an “education” Governor 19881988Medical Schools War of 1991Medical Schools War of 1991ed ca Sc oo s a o 99ed ca Sc oo s a o 99Passage and reauthorization of Passage and reauthorization of legislation 1991, 1995, 1998, 2001, legislation 1991, 1995, 1998, 2001, 20062006W.K. Kellogg CPI grant 1992W.K. Kellogg CPI grant 1992--19961996Rural Health Advisory Panel Rural Health Advisory Panel R&R committee 1998R&R committee 1998AHEC grant 2002AHEC grant 2002

6

WV LegislationWV LegislationRural Health Initiative Act HB 213 Rural Health Initiative Act HB 213 Oct. 18, 1991 (code reference: Oct. 18, 1991 (code reference: §§18B18B--1616--1)1)•• Established 16 performance goalsEstablished 16 performance goals•• Established powers and duties of Vice Established powers and duties of Vice

Chancellor for Health SciencesChancellor for Health Sciences•• Created State Rural Health Advisory Created State Rural Health Advisory Created State Rural Health Advisory Created State Rural Health Advisory

PanelPanel•• Establishment and operations of Establishment and operations of

primary care training sitesprimary care training sites•• Allocation of appropriationsAllocation of appropriations

WV Legislation con’tWV Legislation con’tRecruitment and Retention Committee Recruitment and Retention Committee

placed in code in 1998 placed in code in 1998 §§18B18B--1616--6(f):6(f):placed in code in 1998 placed in code in 1998 §§18B18B 1616 6(f):6(f):

Duties: facilitate statewide and Duties: facilitate statewide and interagency coordination around R&R interagency coordination around R&R need and financial incentivesneed and financial incentives

Links health care and economic Links health care and economic Links health care and economic Links health care and economic development agencies around R&Rdevelopment agencies around R&R

Reports annually to legislatureReports annually to legislature

7

West Virginia

EDUCATIONAL PIPELINEPublic School

7-12 GradeCollege Postgraduate Community

PracticeProfessional Education

Financial Incentive HSSP MSLF

K-12 Programs

Rural Preceptors & Academic AffiliationsWVRHEP

WVAHECRural Rotations C i

and Assistance Programs

SLRPRRCP

HSSP, MSLFSEARCH

Rural Scholars

Rural Rotations

HCOPCommunity Based

Strategies

2008 WVRHEP/AHEC Infrastructure2008 WVRHEP/AHEC Infrastructure

533 training sites in 55 counties533 training sites in 55 counties

800 li i l fi ld f l800 li i l fi ld f l800 clinical field faculty800 clinical field faculty

8 regional consortia with local boards 8 regional consortia with local boards and 4 AHEC Centers with local/campus and 4 AHEC Centers with local/campus boardsboards

15 site coordinators, 5 AHEC center 15 site coordinators, 5 AHEC center directors, program and support staff directors, program and support staff

17 Learning Resource Centers17 Learning Resource Centers

8

Types of Training SitesTypes of Training Sites

•• CHCsCHCs•• FQHCs FQHCs QQ•• RHCsRHCs•• Small rural hospitals & CAHsSmall rural hospitals & CAHs•• Dental officesDental offices•• PharmaciesPharmacies•• Home health agenciesHome health agenciesHome health agenciesHome health agencies•• Schools and school based clinicsSchools and school based clinics•• Etc.Etc.

WVRHEP/AHEC InfrastructureWVRHEP/AHEC Infrastructure

100 student rotations per month100 student rotations per monthSt t l l R l H lth Ad i St t l l R l H lth Ad i State level Rural Health Advisory State level Rural Health Advisory Panel specified in legislation Panel specified in legislation serves both state and federal serves both state and federal functionsfunctions$2.4 million per year to $2.4 million per year to

iti $4 illi t iti $4 illi t communities, $4 million to communities, $4 million to schools for rural health trainingschools for rural health training$100K per AHEC center in federal $100K per AHEC center in federal fundingfunding

9

Outcomes of WV’s Outcomes of WV’s Pipeline Partnership Pipeline Partnership

Programs Programs

HSTA OutcomesHSTA Outcomes95% enter college vs. 56% 95% enter college vs. 56% for all WVfor all WV

59% in health career majors 59% in health career majors VS 17% for all WVVS 17% for all WV

786 (80%) of the 982 HSTA 786 (80%) of the 982 HSTA graduates are still in collegegraduates are still in college

10

HSTA OutcomesHSTA Outcomes

55 HSTA Scholars in 55 HSTA Scholars in graduate/prof schoolgraduate/prof schoolgraduate/prof schoolgraduate/prof school

27 HSTA Scholars in health 27 HSTA Scholars in health sciencessciences

10 HSTA graduates currently 10 HSTA graduates currently in medical schoolin medical school

Discipline Number in Rural Practice

Number w Fin. Incentives

Physicians (1991-2005 graduates) 289 101 (35%)

Nurse Practitioners/Nurse Educators 106 49 (46%)

Nurse-Midwife 1 ·

Physician Assistants 181 50 (28%)Physician Assistants 181 50 (28%)

Nurses 89 ·

Dentists 111 2 (2%)

Dental Hygienists 26 ·

Pharmacists 199 ·

Physical Therapists 59 3 (5%)

Occupational Therapists 59 3 (5%)

Medical Technologists 8 ·

Masters in Public Health 1 ·

Social Worker 1 ·

TOTAL 1072 205 (19%)

11

Physician R&R 1999 to 2008Physician R&R 1999 to 2008Number of physicians who did RHEP rural Number of physicians who did RHEP rural rotations and are currently practicing in rural rotations and are currently practicing in rural areas has increased steadily from 88 to 289.areas has increased steadily from 88 to 289.

The rural practice site of each DO & MD The rural practice site of each DO & MD graduate is regraduate is re--verified annually so the count verified annually so the count each year reflects the loss of some rural each year reflects the loss of some rural practitioners to urban and outpractitioners to urban and out--ofof--state state practice. practice.

Despite this expected loss, the number of Despite this expected loss, the number of medical graduates in rural practice has medical graduates in rural practice has increased dramatically in the past 10 years at increased dramatically in the past 10 years at an average annual rate of 14.1%.an average annual rate of 14.1%.

Physicians with RHEP Rotations Practicing in Rural Ares of West Virginia, 1999-2008

12

R&R Committee of RHEP/AHEC coordinates R&R Committee of RHEP/AHEC coordinates Five State/Federal Incentive ProgramsFive State/Federal Incentive Programs

•Target financial incentives to students and physician residents

•Combine incentive with rural training (i.e. complete special community based projects, research, etc.)

• Package multiple programs for highly promising candidatespromising candidates

•The National Health Service Corps (NHSC) Loan Repayment Program as the Bureau for Public Health assists physicians in applying to this program.

Recruitment Incentives for Rural PracticeRecruitment Incentives for Rural Practice

West Virginia Higher Education Policy CommissionHealth Sciences Scholarship Program 93

WV Rural Health Education PartnershipsSEARCH Training Stipends 43Community Scholarship Program 7

Bureau for Public Health, Division of Rural Health & RecruitmentRecruitment & Retention Community Project 92

St t L R t P 30State Loan Repayment Program 30

NHSC Loan Repayment Program 13

TOTAL 278 Awards

13

RETENTION RETENTION Medical School Graduates from 1998Medical School Graduates from 1998--

2003 Practicing in West Virginia2003 Practicing in West Virginia

Of 1,141 graduates of the state’s Of 1,141 graduates of the state’s three medical schools three medical schools

38% are practicing in West Virginia.38% are practicing in West Virginia.

9.5% are practicing in rural areas.9.5% are practicing in rural areas.

Graduates with Completed Training, 1998-2003

# Primary

InstitutionsTotalGraduates

Total# WV

yCare in WV # Rural

West Virginia University 514 481 176 (36.6%) 95 (19.8%) 34 (7.1%)Marshall University 289 273 112 (41.0%) 68 (24.9%) 20 (7.3%)WV School of

Osteopathic Medicine387 387 143 (37.0%) 109 (28.2%) 54 (14.0%)

TOTAL 1,190 1,141 431 (37.8%) 272 (23.8%) 108 (9.5%)

14

OutcomesOutcomes

State has eliminated 8 HPSA State has eliminated 8 HPSA ti i 10 91 h lth ti i 10 91 h lth counties in 10 years; 91 health counties in 10 years; 91 health

professionals in these counties professionals in these counties completed required rural rotations completed required rural rotations

In 10 years rural physicians who In 10 years rural physicians who In 10 years rural physicians who In 10 years rural physicians who complete this training increased by complete this training increased by 228%, annual rate of 14%228%, annual rate of 14%

OutcomesOutcomesWV Schools of Medicine consistently WV Schools of Medicine consistently

ranked above national averagesranked above national averages

•• US News and World Reports Best US News and World Reports Best Graduate SchoolsGraduate Schools

•• AAMC and AACOM master file dataAAMC and AACOM master file data

•• AAFP for 3 years at or above 15% of AAFP for 3 years at or above 15% of graduates who go into primary caregraduates who go into primary care

15

Practice Location 7 to 10 years after Practice Location 7 to 10 years after Graduation and Medical School Graduation and Medical School

Attended by WV Physician Attended by WV Physician Workforce 1981 to 2006Workforce 1981 to 2006

Study commissioned by WV HEPC to Study commissioned by WV HEPC to Cecil B. Sheps Center, UNC, Cecil B. Sheps Center, UNC,

hhDon Pathman, MD, MPHDon Pathman, MD, MPH

Pathman Report Findings, con’tPathman Report Findings, con’t"From 1981 to 2006 the number of "From 1981 to 2006 the number of physicians in rural West Virginia physicians in rural West Virginia increased by 52%, from 881 to increased by 52%, from 881 to increased by 52%, from 881 to increased by 52%, from 881 to 1,339." (Even with this increase, WV 1,339." (Even with this increase, WV primary care workforce remained primary care workforce remained stable) stable)

Pathman attributes this to "increase Pathman attributes this to "increase Pathman attributes this to increase Pathman attributes this to increase in number of practicing graduates in number of practicing graduates from WV's schools . . .“from WV's schools . . .“

16

Location of Physicians (Location of Physicians (Primary CarePrimary Care and and NonNon--Primary Primary CareCare) Who Graduated from WV's ) Who Graduated from WV's Three Medical Three Medical

SchoolsSchools 7 to 10 Years Earlier7 to 10 Years Earlier

400

450

150

200

250

300

350

umbe

r of

Gra

duat

es

Outside WVWithin WVUrban WVRural WV

0

50

100

1981 1986 1991 1996 2001 2006

Year

Nu

Pathman Report FindingsPathman Report Findings

"As of 2006, 13% of physicians who "As of 2006, 13% of physicians who graduated from all 3 med schools 7graduated from all 3 med schools 7--graduated from all 3 med schools 7graduated from all 3 med schools 710 years earlier were working within 10 years earlier were working within rural areas of the state 7 to 10 years rural areas of the state 7 to 10 years after graduation.“after graduation.“

"Among primary care graduates, the "Among primary care graduates, the ti ki i l f ti ki i l f proportion working in rural areas of proportion working in rural areas of

West Virginia remained stable from West Virginia remained stable from 1991 to 2006, at about 14%."1991 to 2006, at about 14%."

17

Location of Location of Primary CarePrimary Care Physicians Who Graduated from Physicians Who Graduated from WV's WV's Three Medical SchoolsThree Medical Schools 7 to 10 Years Earlier7 to 10 Years Earlier

200

250

100

150

200N

umbe

r of

Gra

duat

es

Outside WVWithin WVUrban WVRural WV

0

50

1981 1986 1991 1996 2001 2006

Year

N

Pathman Report FindingsPathman Report Findings

Among graduates of all 3 medical Among graduates of all 3 medical schools "As of 2006 more than schools "As of 2006 more than schools, As of 2006, more than schools, As of 2006, more than half (54%) were practicing in half (54%) were practicing in primary care specialties 7 to 10 primary care specialties 7 to 10 years after graduation. years after graduation.

Thi i i ifi tl hi h Thi i i ifi tl hi h This is a significantly higher This is a significantly higher proportion than reported proportion than reported elsewhere for graduates of other elsewhere for graduates of other statesstates."."

18

Pathman Report FindingsPathman Report FindingsOverall, the proportion of graduates of WV's Overall, the proportion of graduates of WV's three schools practicing in rural areas of WV three schools practicing in rural areas of WV was decreasing from 1986 to 1996, then was decreasing from 1986 to 1996, then turned around and increased from 1996 to turned around and increased from 1996 to 2006200620062006

1996 to 2006 is the exact time period when 1996 to 2006 is the exact time period when WVRHEP participants were graduating and WVRHEP participants were graduating and appearing in the workforce. appearing in the workforce.

“We cannot know for sure, but can suspect “We cannot know for sure, but can suspect th t th d t d f 1996 t 2006 i th t th d t d f 1996 t 2006 i that the upward trend from 1996 to 2006 is that the upward trend from 1996 to 2006 is due to RHEP and that the impact of RHEP due to RHEP and that the impact of RHEP was to convert a falling rate of rural was to convert a falling rate of rural physician production from the state's physician production from the state's schools to a 86% increase, with the schools to a 86% increase, with the percentage of WV grads practicing in rural percentage of WV grads practicing in rural WV from 7% WV from 7% (1996) to 13% (2006).”(1996) to 13% (2006).”

Pathman Report Findings, con’tPathman Report Findings, con’tSignificant finding is that in 20 to 25 years, Significant finding is that in 20 to 25 years, WV has reversed the medical school origins of WV has reversed the medical school origins of physicians practicing in WV. physicians practicing in WV.

These graphs show that in 1981 far more of These graphs show that in 1981 far more of WV's physicians were trained in other states WV's physicians were trained in other states and internationally than were trained in state and internationally than were trained in state schoolsschools

With th i d ti f With th i d ti f With the expansion and creation of new With the expansion and creation of new schools in the 1970s and 1980s that by 2006 schools in the 1970s and 1980s that by 2006 significantly more physicians practicing in WV significantly more physicians practicing in WV were trained in WV than were trained were trained in WV than were trained elsewhere.elsewhere.

19

Changes from 1981 to 2006 in Number of Clinically Active Physicians Changes from 1981 to 2006 in Number of Clinically Active Physicians in WV Who Graduated from Medical Schools within the State, in WV Who Graduated from Medical Schools within the State,

Elsewhere in the US and Canada, and Outside the USElsewhere in the US and Canada, and Outside the US

1600

1800

600

800

1000

1200

1400

umbe

r of P

hysi

cian

s

InternationalU.S./CanadaWest Virginia

0

200

400

1981 1986 1991 1996 2001 2006

Year

Nu

Changes from 1981 to 2006 inChanges from 1981 to 2006 in Number of Clinically Active Physicians Number of Clinically Active Physicians in RURAL WV Who Graduated from Medical Schools within the State, in RURAL WV Who Graduated from Medical Schools within the State,

Elsewhere in the US and Canada, and Outside the USElsewhere in the US and Canada, and Outside the US

500

600

200

300

400

500

mbe

r of P

hysi

cian

s

InternationalU.S./CanadaWest Virginia

0

100

1981 1986 1991 1996 2001 2006

Year

Num

20

Oct 2006 HRSA Health Oct 2006 HRSA Health Workforce study (2004 data)Workforce study (2004 data)

31% of WV’s physician 31% of WV’s physician p yp yworkforce are graduates of workforce are graduates of instate medical schools while instate medical schools while national average is 29%. national average is 29%.

38% of the WV physician 38% of the WV physician workforce are international workforce are international graduates, compared to a graduates, compared to a national average of 26%.national average of 26%.

Comparison of AMA Master file Data and WVRHEP Data on Percentage of WV Medical Graduates working in WV and in Rural WV

AMA Master file Data WVRHEP data

Percentage of WV medical school graduates

40% of those students who graduated between

37% for those students who graduated betweenmedical school graduates

working in WVwho graduated between

1996-1999who graduated between

1998-2005

Percentage of WV medical school graduates working in rural* WV

13% of those students who graduated between

1996-1999

11.3% for those students who graduated between

1998-2005

Percentage of West Virginia School of

22% of the WVSOM students who graduated

19% of the WVSOM students who graduatedVirginia School of

Osteopathic Medicine (WVSOM) graduates working in rural* WV

students who graduated between 1996-1999

students who graduated between 1998-2005

*Urban = the 12 metropolitan counties identified by the OMB in 1999 + Monongalia County (the home of WVU Health Sciences Center). Rural = the 42 other WV counties.

21

NRHA Policy Papers on RH NRHA Policy Papers on RH WorkforceWorkforce

Defining the Issues and Principles Defining the Issues and Principles of R&Rof R&R

http://www.ruralhealthweb.org/go/left/polichttp://www.ruralhealthweb.org/go/left/policyy--andand--advocacy/policyadvocacy/policy--documentsdocuments--andand--statements/issuestatements/issue--paperspapers--andand--policypolicy--briefs/briefs/

Visit us Visit us on the on the WebWeb

www.wvrhepahec.org

www.wv-hsta.org

22

Contact InformationContact Information

www.wvrhepahec.orgwww.wvrhepahec.org

Hilda R. HeadyHilda R. Heady304.293.4966304.293.4966304.288.9003304.288.9003hheady@hsc.wvu.eduhheady@hsc.wvu.edu