November 12, 2018
Are we running out of specialists?
By Marcia Frellick
The following article is our featured cover story in the November/December 2018 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may purchase a subscription.
Patients in parts of Washington seeking care from specialists can face months-long waits for appointments and long drives. The latest estimates show dire shortages in many specialties and some are on track to get much worse in the coming decades.
Reports are lacking on the precise deficits, partly because the definition of "specialty" is different among government entities, because people are seeking the care across county and state lines, and because no one entity in the state tracks shortages in all specialties, said Renee Fullerton, workforce programs manager with Washington state's Department of Health.
Anecdotally, experts say the biggest shortage is in psychiatry and behavioral health. A physician workforce report in 2016 by the University of Washington Center for Health Workforce Studies showed only 727 psychiatrists delivering direct patient care in the state (10.1 per 100,000 population) and more than half of the state's psychiatrists were 55 or older. And that number dwarfs the number of behavioral/mental health/addiction specialists in Washington. That specialty has only 0.3 per 100,000 population in the state.
Ray Hsiao, MD, a child and adolescent psychiatrist practicing in Seattle, said about one-fourth of the counties in Washington don't have a single psychiatrist.
Driving the shortage, he said, are two main factors: too few training slots and insurance networks that have narrowed so much that patients can't find a psychiatrist who is taking new patients.
"If reimbursement were better, more would be able to take on new patients," he said.
Therefore, the most promising solutions currently lie in extending the reach of those already practicing, he said.
Dr. Hsiao pointed to the "collaborative care" approach developed by the UW as well as the university's AIMS (Advancing Integrative Mental Health Solutions) Center, which is the role model nationally, he said. The idea is that a mental health team of specialists in a central location helps primary care physicians and providers serve patients with mental health issues in their communities.
Traditional telemedicine would open up access, he said, but it needs to work in tandem with people located near the patient to help follow through on care.
"With telepsychiatry, you don't really know who you're seeing and you're working with them remotely," Dr. Hsiao pointed out.
Shortages of rheumatologists climbing
Some of the other areas of highest need include rheumatology, neurology, and some surgical subspecialties. Nationally, a 2015 American College of Rheumatology workforce study shows the demand for rheumatologists exceeded supply by 700 full-time physicians in 2015. The shortage is expected to soar to 4,133 by 2030 with increased demand, retirements, and more physicians working part-time.
Jeff Peterson, MD, president of the Washington Rheumatology Alliance, said Washington has only about 75 full-time rheumatologists and many regions in the state don't have any. A few big reasons behind the shortage, he said, are the relatively lower pay for rheumatologists because they perform fewer procedures, a lack of training spots for rheumatologists, early retirements, and the pressure to work in hospital systems that are buying up independent practices.
"You spend two more years in training and you're going to earn about the same as an internist," he said.
But perhaps more important than the pay gap is the pressure to join hospital systems, he said.
"We're the cowboys; we think out of the box," Dr. Peterson said. "We're the last stop for most people when they try to figure out the disease process. That spirit needs to be fostered and I think it's being squelched by people who say, 'You need to do it this way.'"
Dr. Peterson said the alliance is reaching out to fellows to let them know they have choices. If they do want to practice independently, the alliance can offer support on how to set up smaller businesses. The hope is that will help keep up rheumatologists' satisfaction rates and keep them in the state, he said.
Lack of rheumatologists in surrounding states mean patients are turning to Washington for help, contributing to wait times that range from three to six months, he said.
It's even worse for pediatric patients, Dr. Peterson said, because those specialists are all at one hospital, Seattle Children's.
Geographic disparities nationally are stark as well and numbers show rheumatologists are often centered in urban or suburban areas. The 2015 ACR study showed that 21 percent of adult rheumatologists are in the Northeast and 3.9 percent are in the Southwest.
Another area of significant need in Washington is neurology. According to the American Academy of Neurology, Washington had 351.9 neurologists in 2012, 51.3 short of the number needed to meet current demand. By 2025, the shortage is expected to almost double, with a workforce of 411 and a need for 508, leaving a shortage of 97 neurologists.
Looking for answers
Across the state, many are looking to telehealth as a solution. John D. Scott, MD, medical director for University of Washington Telehealth, said telehealth is advancing on three fronts. One is the Project ECHO (Extension for Community Healthcare Outcomes) program, under which primary care physicians all over the Northwest and in rural areas link with a group of specialists at a weekly teleconference and present cases so they can help deliver the care in primary care settings.
Another is the electronic consult system for primary care providers who have a question about a patient or are on the fence about whether the patient needs a specialist. The physician can send a message through the electronic health record to a pool of specialists and the appropriate specialist answers on how to proceed.
"The beauty of using the EHR is a lot of the relevant data is already in the EHR," Dr. Scott said. "We're now doing that for 14 different specialties and have had more than 4,000 patients who have benefited from this," he said. "A good example is in dermatology; we do about 150 consults a month."
The third route is traditional telemedicine with video and high-tech imaging. UW physicians can consult remotely and determine what medications are needed and whether the patient needs to be transported for further care.
However, traditional telemedicine has been stuck because of payment barriers that often make performing the service cost-prohibitive for physicians, Dr. Scott said.
"The idea is we try not to move people, but to move the knowledge," Dr. Scott said. "We're trying to make the primary care physicians work at the maximum of their training and trying to keep more patients in their communities."
A smaller program to add specialists, managed by Fullerton at the DOH, is the J-1 physician visa waiver program. Washington state employers can sponsor international physicians who have done their residencies and fellowships to work in an underserved area of Washington for three years.
However, only about 15 specialists are part of the program each year and the program must be a last resort. Employers have to show that have tried and failed to find an American candidate. Typically, the spots have been vacant for quite a long time, Fullerton said.
"It's not a first-line option, but it's a way to get access to care," she said.
Legislative wins for specialists
Katie Kolan, JD, director of legislative and regulatory affairs for the WSMA, said the association has successfully fought for changes in the legislature that have provided support for the state's specialists.
The WSMA was also able to help fend off the state's attempts to prohibit balance billing—the practice of charging patients for the difference between the dollar amount a provider bills for a service and the amount an insurer is willing to pay.
"Balance billing is a big [issue] for anesthesiology, emergency departments, radiology, and pathology," she said.
Even more significant was the passage of the Interstate Medical Licensure Compact, signed into law in 2017, which will make it easier for physicians to practice in any state that is a partner to the compact rather than having to go through each state's licensing demands.
"It's really important for specialists to be able to practice across multiple states," she said, "especially in the age of telemedicine."
Marcia Frellick is a freelance journalist who specializes in health care topics.