The Lack of Evidence of an Emergency Physician Workforce Shortage in Florida

The Lack of Evidence of an Emergency Physician Workforce Shortage in Florida

By David Orban, MD, FACEP and Barbara Langland Orban, PhD

In 2012, the Department of Health initiated a survey to assess the state’s current and future physician workforce needs and prepared a report on the physician workforce in Florida. Every year since, a summary analysis of the Physician Workforce Survey is completed. Physicians are required to complete the survey every two years when they renew their medical license. This report helps policymakers make informed decisions about Florida’s current and future physician workforce and access to care.

The 2017 Workforce Report includes the following key points:

• A total of 66,988 physicians renewed their medical license during 2016 and 2017 and responded to the workforce survey.

• Nearly two-thirds (61.9%) of physicians are age 50 years or older.

• Of the 14 specialty categories, all but one specialty (emergency medicine) has more than 25% of physicians age 60 and older.

• On-average, emergency physicians are significantly younger than Florida physicians at-large (45 vs. 55).

• Emergency physicians are notably concentrated in coastal areas and in areas containing medical schools and large population centers.

• Florida is below the national median of active primary care physicians of 9.1 per 10,000 population, having only 7.7 primary care physicians per 10,000 population (defined as general internal medicine, family medicine and pediatrics). (AAMC 2016 State Physician Workforce Data Book)

• In 16 of Florida’s 67 counties, over 20% of primary care physicians plan to retire in the next five years.

New medical schools have opened in Florida, and existing schools have expanded since 2010 to meet increased demand. However, this has created more applicants for a limited amount of Florida residency slots. For each available slot, a residency program may have hundreds of applicants.

The shortage in primary care is especially compounded by Florida’s lack of primary care residency slots. In 2012, for example, New York offered about 1,500 residency slots in internal medicine. In Florida, there were just 482. Similar disparities in training numbers were found in pediatrics, family practice, general surgery, psychiatry and obstetrics (physicians willing to perform deliveries), and the annual Florida Physician Workforce Report has projected major shortfalls citing these as “critical shortage specialties.”

The 2013 Florida legislative session resulted in the passage of SB 1520, which repealed the Community Hospital Education Act (s.381.0403, Florida Statutes) and established the Statewide Medicaid Residency Program. The state has offered incentives to create more residency positions, providing $80 million in recurring state and matching funds in 2013 to create a program that funds new residency slots.

In 2015, legislators provided $100 million to give participating community hospitals $150,000 for every residency position created in a “critical shortage specialty,” but restricted to hospitals that did not previously have residency programs. The Agency for Health Care Administration provides the funds to hospitals based on certain criteria and a formula for calculating each participating Medicaid hospital’s portion. The Physician Workforce Advisory Council has continued to provide guidance to both the Department of Health and the Agency for Health Care Administration, as requested, to assure compliance with the Statewide Medicaid Residency Program as enacted by SB 1520.

The original draft of SB 1520's during the 2013 legislative session followed a template of similar bills in 12 other states facing similar physician shortages and listed only the six “critical shortage specialties” (internal medicine, family medicine, pediatrics, psychiatry, OB/GYN, general surgery) as eligible for funding new residencies. As the Florida bill made its way through the various Senate committees, emergency medicine was oddly added to the list of “critical shortage specialties,” making Florida the only state to add EM to the new residency funding list.

HCA Healthcare and others have brought more residency positions to Florida and other parts of the country by turning community hospitals into teaching hospitals. In the next five years, HCA plans to expand its residency positions in Florida from 767 to 2,115. The hospital chain received state incentives through the Statewide Medicaid Residency Program for these new residency positions. All of the newly-minted positions will become eligible for federal funding once the programs have been in place for five years.

A report in 2017 showed that Florida hospitals increased the number of residency slots in all specialties by 19% since 2013. In the same timeframe, the number of slots in emergency medicine increased by 198%. With the recent RRC-EM approval of three more new EM residencies in April 2018, the 5-year growth of ERAS matching EM slots in Florida will be nearly 260%.

How did the specialty of emergency medicine in Florida get to this place? Was there, in fact, a “critical shortage” of emergency physicians in the state, or was this a myth of epic proportions? To answer this question, we went back to the publicly-available data in the annual DOH Physician Workforce Surveys and the Agency for Health Care Administration (ACHA) Emergency Department Visit data.

Based on Florida licensing data, 2205 physicians listed themselves as board-certified in emergency medicine in 2013. By 2017, that number had increased to 2452 — a 4-year increase of 11%. Over the same period, total ED visits in Florida grew from 9,387,465 to 10,737,365 — a 14% gain. However, a significant part of that growth was due to a substantial increase of licensed free-standing EDs in Florida. A closer examination of traditional hospital ED visits over the same period showed a more modest gain of 9.7% (7,548,543 in 2013 to 8,283,346 in 2017). In fact, 2017 was the first year in ACHA ED Data history that the number of hospital ED visits actually dropped from the previous year (8,318,350 in 2016 down to 8,283,346 in 2017). The Florida population only increased 7% over the same period (19,580,000 in 2013 to 20,980,000 in 2017).

A simple calculation demonstrates that in 2017, all the ED visits in Florida could have been seen by the 2452 emergency physicians working alone at a rate of 2.28 patients per hour. Of course, we know that workforce projections are much more complex than just dividing the patients by physicians by hours.

Physician extenders have become commonplace, typically seeing lower acuity patients. Meanwhile, ED patient volumes continue to rise each year. Despite increases in the number of emergency physicians and increased use of physician extenders, ED lengths of stay continue to rise, and our EDs are becoming increasingly crowded in response to an aging population, higher acuity, increased regulation and more available advanced testing. National workforce studies project that there will be a continued need for more emergency physicians, particularly in rural underserved areas—a trend that reflects the overall undersupply of physicians in the United States. Due to the numerous variables involved and the statistical complexities, a more sophisticated analysis is required to project Florida’s future emergency provider needs.

Conclusion

Is there currently a shortage of board-certified emergency physicians in the United States? Yes, although it is decreasing steadily each year and not relevant to Florida. Is there currently a shortage of emergency physicians in Florida? The Florida Department of Health says there is no shortage. The annual DOH Physician Workforce Survey does not include emergency medicine in its list of shortage specialties. Emergency medicine should never have been quietly slipped into the list of “critical shortage specialties” on SB 1520 back in 2013.

The fact of the matter is that when APP coverage is factored in, Florida has an adequate number of emergency providers. Many previous physician workforce studies have recognized that emergency physicians, for the most part, do not want to work in isolated rural hospitals or low-income areas where the pay is also low. However, this is not just a Florida problem—it is a national problem that leaders of our specialty must acknowledge, address and solve.

So why are we spending our precious Medicaid tax dollars in the precipitous expansion of emergency medicine residency training slots in Florida if there is not a crisis? The primary care physician shortage is compelling and is likely to increase exponentially over time as primary care provider numbers dwindle. The Affordable Care Act, which was signed into law in March 2010, has increased access to medical care by expanding medical insurance coverage, further exacerbating current primary care shortages. Floridians would benefit far more from increasing our primary care workforce rather than permitting state tax dollars to shift an inordinate number of residency training slots into emergency medicine. ■