The report is a call to action: “If we don’t pay greater attention now,” it warns, “there will be a price to pay in the availability and quality of our medical care in the years to come.” Although some of the statistics cited don’t reinforce the case that the Hudson Valley is at particular risk, many of the findings reflect a brewing crisis at the national and state levels that are cause for concern.
The report acknowledges that the issue of physician care is complex throughout the region, with particular needs and issues varying widely by community. Indeed, “the key word here is maldistribution,” noted Kathryn Reed, author of the report and the executive director of the Catskill-Hudson Area Health Education Center, based in Ulster County and in economically underserved areas such as Ellenville, Newburgh and Beacon. On the other hand, a focus group of doctors that Reed interviewed for the report noted that Kingston — which has no shortage of primary-care doctors, thanks to a flourishing family residency training program — is faced with a different challenge: not enough specialists.
The report cites statistics from the region and state demonstrating two trends that are on a collision course: the aging of the population and a falling-off in the number of physicians, particularly primary-care providers. For example, according to the 2008 Physicians Workforce Profile compiled by The Center for Health Workforce Studies at the School of Public Health at SUNY-Albany, there are physician shortages in the areas of general surgery, orthopedics, urology and psychiatry. However, these shortages are not unique to the Hudson Valley. (Indeed, a look at the CHWS’s workforce studies report for 2009 indicates that the Hudson Valley was nearly equivalent to Long Island in the number of active full-time physicians in 2008: both were nearly 100 physicians for every 100,000 people, and only New York City had a higher ratio, at exactly 100.)
Another issue is the aging of doctors themselves. The report notes that active-care physicians are older in the Hudson Valley than in the state as a whole — but only by two years. (In 2008, it was 53, compared to 51 for the state.) In Ellenville, however, there is a real concern, with several much older physicians on the verge of retirement.
These quibbles aside, the issues the report raises about the challenge in recruiting physicians in the near future is spot-on, according to Dr. Eugene Heslin, owner (and one of six of practicing physicians) of Bridge Street Family Medicine, located in Saugerties. Heslin was recently named chairman of the board at Health Alliance of the Hudson Valley. He and HealthAlliance president and CEO David Lundquist confirmed the report’s findings about the difficulties of recruiting physicians to the region: the lack of an academic environment (related to the problem in attracting specialists), limited job opportunities for spouses, and the demands of smaller call-coverage groups (doctors have to be on call more because the groups of practicing physicians are smaller here than in a large urban area).
The perception that Kingston has a shortage of medical specialists is a factor in the outmigration of 51 percent of patient care in Ulster County, said Lundquist. He said, however, that the alignment of the city’s two hospitals under the HealthAlliance organization is resulting in a strengthening of specialty care. “We have twelve neurologists, nine cardiologists, and we’re working with the Orthopedic Associates of Dutchess County,” he said, naming a few of the initiatives afoot.
In fact, the formation of HealthAlliance is giving Kingston a recruitment advantage, he claimed. “We’re creating a different environment for the patients and physicians and addressing that 51 percent outmigration. We’re in the best position to attract physicians.”
That’s not to discount the fact that recruiting physicians in New York is much more difficult than anywhere else, said Lundquist (who prior to joining HealthAlliance worked in New Jersey and the southwestern U.S.). He noted the high cost of operations due to the state’s numerous regulations, the exorbitant malpractice liability insurance premiums, and insurance reimbursement rates that are much lower than in neighboring states. He said these factors result in lower profit margins for hospitals and physicians’ practices. Given that hospitals in Dutchess and Orange counties are reimbursed for Medicare at rates 30 percent higher than in Kingston — the amounts for the neighboring counties are identical to the federal government’s designation for New York City, which because it has higher wages gets a higher reimbursement — HealthAlliance is at a competitive disadvantage, with nurses and other medical staff able to make $3000 more a year in other counties.
The real challenge in recruiting physicians in the near future, however, is tied to national trends. Heslin noted that the number of geriatricians in the nation had declined from 9000 in 1998 to 7000 in 2008 and was expected to fall 20,000 short of the 35,000 that will be needed to serve the aging population of baby boomers by 2025. A decline in the nation’s primary-care physicians is due to simple economics: the average debt for medical-school graduates is now around $180,000, which means more young doctors will choose to practice in the higher-paying specialties.
The salary differential is huge. A neurologist can make six to seven times more and a surgeon three to four times more than a general practitioner, according to Heslin. He also agreed with the report’s finding that younger doctors aren’t working as many hours as their predecessors, which will reduce the available care for an aging population.
The aging of the population is causing a shrinking of the tax base, which will further squeeze health-care resources. While in 1965 20 people supported one person age 65 or older, today it’s ten, and in ten years it will be three people supporting one person age 65 or older, Heslin said. Two additional factors will exacerbate the pressure on the health-care system: the greater demand from an older population and the increase in much older people (the average life span is increasing, from 68 in 1965 to 77 today to 84 in 2020, if trends continue the same).
So it’s likely communities all over the country will soon be competing for a dwindling pool of physicians. Reed’s report suggests the solution in our area is a stepped-up recruitment effort, including offering incentives such as medical-school loan forgiveness programs and tax abatements for new practices in needed specialties; more R&D for local universities; and a speeding up of the credentialing process for new doctors by hospitals.
Reed noted her agenda in researching the report was to identify health manpower shortages and develop programs to address them, which is the mission of the Catskill-Hudson Area Health Education Center. The center has established a recruitment “sustainability program” for the Wawarsing-Ellenville area, and in conjunction with the local community is raising “incentive pools” of money from businesses to help forgive doctor loans. Another incentive designed to lure more doctors to the area comes from revolving loans with favorable interest rates from the local government.
Kingston isn’t in the dire straits of Ellenville. Indeed, Reed’s report concludes that Kingston is in a good position because of the “enormous health-care buying power” of local government. “The premiums paid to those public employees in Ulster County alone in 2008 approached $100 million,” it notes. Perhaps one shouldn’t tell that to a local taxpayer, who just might have a heart attack.++