Maternity Workforce In Iowa

MATERNITY WORKFORCE IN IOWAMarygrace Elson, MD, MME, FACOGPresident, Iowa Medical Society

Approximately 1/3 of births in IA are in rural settings FM physicians deliver more in rural settings; andOBGs and CNMs more in urban settings OBGs deliver approximately 70% of births Family physicians deliver approximately 16% Number of FM grads from UIowa affiliated programspracticing OB has halved over the last 20 yrs ( 20% for 2018 grads)- mirrors national trends Iowa ranks last in the USA for # OBGs/10,000 women

Provider Workforce2017 State Physician Workforce Data BookAssociation of American Medical CollegesMetricIowa MeasureNational RankingPhysicians Per Capita211.443rdActive Physicians Over Age 6028.7%39thMedical Students Per Capita49.410thResidents/Fellows Per Capita28.125thSpecialtyPrimary GYNRank35th39th39th41st44th52ndCOPYRIGHT 2019 IOWA MEDICAL SOCIETY. ALL RIGHTS RESERVED.

Provider Workforce

Provider WorkforceDISTRIBUTION OF PHYSICIANASSISTANTSSource: AMA Health Workforce Mapper Based Upon State Licensure DataCOPYRIGHT 2019 IOWA MEDICAL SOCIETY. ALL RIGHTS RESERVED.

Provider WorkforceDISTRIBUTION OF ARNPSSource: AMA Health Workforce Mapper Based Upon State Licensure DataCOPYRIGHT 2019 IOWA MEDICAL SOCIETY. ALL RIGHTS RESERVED.

Provider WorkforceFamily Medicine*Internal Medicine**25%38%General l Other Specialties4%6%8%4%4%5%*Includes residencytrained FM practicingEmergency Medicine**IncludessubspecialtiesSource: Office of Statewide Clinical Education Programs, UI Carver College of MedicineIowa Health Professions Tracking Center, July 2018COPYRIGHT 2019 IOWA MEDICAL SOCIETY. ALL RIGHTS RESERVED.

MATERNITY CARE IN THE RURAL USAIn 1985, 24% of ruralcounties lacked OBservices. Today, 54% ofrural counties arewithout hospital basedobstetrics.More than 200 ruralmaternity wards closedbetween 2004 and2014.Half of rural women livemore than 30 mins driveto maternity unitHigher incidence of Chronic conditions Poverty Travel barriersPutting pregnant women at riskHigher incidence of out of hospitalbirth and other pregnancycomplications

Closed 2018Closed 2019

MATERNITY DESERTS IN RURAL IOWAAccess in Iowa is 18 OB providers per100,000 prospective mothers

MATERNITY CARE IN RURAL IOWA 2013-2018COUNTIES WITHOUT L AND D UNIT5x incidence of out of hospital birth incounties without L and D unit(2.5%)Distance to drive to L and D unit24% less than 30 minutes62% 30-60 minutes14% 60 minutes or moreUnpublished data IDPH, UICCOM Office Statewide Programs

WHY DO MATERNITY UNITS CLOSE?July 2019 OB Workforce Study from the Wisconsin Officefor Rural Health:Lack of provider coverageProviders unable to keep up skillsLow or reduced volume of deliveries compared to cost ofkeeping unit staffed 24 x 7 x 365.100 births/year seems to be the critical threshold11 of Iowa’s 63 remaining maternity units deliver 100/yearObstetric Delivery Servies and Workforce in Rural WisconsinHospitals, WI office of Rural Health, July 2019.

KEEPING THE LIGHTS ON- PAYMENT FOR MATERNITYSERVICESMedian operating margin at the time hospitals drop OB is 1.3%Hospitals save 2M by closing OB!Contracts cannot be negotiated for an urban area andsame reimbursement applied to a low volume hospitalMedicaid (43% of births in IA)Geographic Practice Cost Index (GPCI)- Medicare

MEDICAL LIABILITY IN IOWA- AN EMERGINGCRISIS5 Cases1. Huitt v. Iowa Clinic (2019) 85 MillionTotal Damages2. Plowman v. Fort Madison Hospital (2019)3. DeJongh v. Sioux Center Health (2018)4. Pellock v. Mississippi ValleyAnesthesiology (2017)5. Phillips v. Flexible Family Care (2017) 63 MillionNoneconomic Damages

Iowa Needs a Hard Capon Noneconomic Damages Maxing out Liability Coverage Draining Reserve Funds Erasing Operating Margins Threatening Access to CareCOPYRIGHT 2019 IOWA MEDICAL SOCIETY. ALL RIGHTS RESERVED.

THE DECLINE OF THE AMERICAN SMALL TOWNAND “BRAIN DRAIN” GlobalizationDecline of industry in “shop towns”Agribusiness and factory farmsBig Box Retailers and Internet Commerce

EDUCATIONAL DEBTAverage debt nationally for indebted USA medical school gradson graduation (including undergraduate debt) 196,520Deferred while in residency/fellowship trainingDebt forgiveness available with some job opportunities upongraduating residencySignificant factor in choosing practice opportunitiesThought to be a driver for national trends ofUrban/suburban practice locationSubspecialization

“Closing OB departments does not mean thathospitals will avoid obstetrics emergencies, just thatthey will not be competent at managing them whenthey happen.”John Cullen, MD, President, AAFP, October, 2018

RETHINK CONCEPT OF MATERNITY CAREPROVIDERSIn addition to maternity units and the nurses and providerswho staff them— EMS staff ED providers and nursing staff Providers and nursing staff in critical access hospitalsTRAIN for rare but catastrophic eventsAAFP ALSO trainingAIM bundlesPROVIDE Web-based Resources

RETHINK HOW WE PROVIDE MATERNITYSERVICESLeverage telemedicine capabilities with paymentparity Subspecialty consultation Provide routine prenatal care utilizingprimary providers in communitiesIntegrated regional perinatal regionalizationsupport for lower levels of maternity care

Rural Loan Repayment Programs: Flexible and Funded Expand OB Fellowship Opportunities for FM Residents Expand UIHC OBG residency to include a rural “track” Preceptor Tax Credits Rural Practice Tax Credits Conrad 30 Program Assistance with medical malpractice liability Assistance with coverage for time away (vaca, CME) Rural Infrastructure and Job Development InitiativesRECRUITMENT AND RETENTION

KEEP IN MINDPeople most often settle in rural locations for personalreasons Know and want the lifestyle Family connections Want to make a differenceCultivate early and often Identify gifted youth who might return Summer fellowships while in college Rural exposures and “tracks” in med school andresidency

ACKNOWLEDGEMENTS AND REFERENCESGreg Nelson, Assistant Dean, University of Iowa Office of Statewide Clinical ProgramsBrock Slabach, Sr. Vice-President, National Rural Health AssociationStephanie Trusty, Nurse Clinician, Iowa Department of Public Health-Patrick J. Carr and Marka J. KefalasHollowing Out the Middle: The Rural Brain Drain and What It Means for AmericaBeacon Press, 2009.Iowa Department of Public Health-Obstetrical Care in Iowa:A Report on Health Care Access to the Iowa State Legislature – Year 2019-Wisconsin Office of Rural HealthObstetric Delivery Services and Workforce in Rural Wisconsin Hospitals, July 2019.

Stephanie Trusty, Nurse Clinician, Iowa Department of Public Health-Patrick J. Carr and Marka J. Kefalas. Hollowing Out the Middle: The Rural Brain Drain and What It Means for America. Beacon Press, 2009. Iowa Department of Public Health-Obstetrical Care in Iowa: A Report on Health Care Access to the Iowa State Legislature -Year 2019