Georgia’s Obstetric Crisis 26 Ga Maternal... · 2015-11-13 · Georgia’s Obstetric Crisis:...
Transcript of Georgia’s Obstetric Crisis 26 Ga Maternal... · 2015-11-13 · Georgia’s Obstetric Crisis:...
Georgia’s Obstetric Crisis: Origins, Consequences, and Potential Solutions
Georgia Senate Study Committee
on Women’s Adequate Healthcare Monday, October 26, 2015
Adrienne D. Zertuche, MD, MPH Georgia Maternal and Infant Health Research Group
of the Georgia Obstetrical and Gynecological Society
Outline
Overview
Origins
Consequences
Potential Solutions
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Georgia’s
Obstetric
Care Crisis
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5 5
Ob Care in Rural Georgia
43 of the 82 Georgia PCSAs* outside of the
Atlanta MSA (52%) have either an overburdening
or a complete absence of obstetric providers
No obstetricians: 31 (38%)
No delivering family practitioners: 73 (89%)
No certified nurse midwives: 57 (70%)
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* Primary Care Service Area: collection of counties in which
>30% of those county residents receive their primary care
* Georgia Board for Physician Workforce. Physician Workforce Resource Center..
5 Status of Obstetric
Services in Georgia
(by PCSA)
Dec. 2011
On average, men stop practicing obstetrics at age 52,
and women at age 44.*
33% 35%
19% 13%
0
5
10
15
20
<45 45-49.9 50-54.9 >55
No. o
f R
ura
l P
CS
As
Average Obstetrician Age
Average Ob Age in Rural PCSAs
≥
6
Retirement of Rural Obs
* Rayburn WF and ACOG. The Ob/Gyn Workforce in the United States, 2011.
Future of Ob Care
43 of the 82 Georgia PCSAs outside of the
Atlanta MSA (52%) have either an overburdening or a
complete absence of obstetric providers
In 16 of 47 rural PCSAs with obstetric providers
(35%), ≥50% of physicians will discontinue care
within 5 to 10 years
By 2020, 58 of 77 rural PCSAs (75%) will lack
adequate obstetric services
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Origins
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5
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Origins of Ob Care Crisis
Provider Trainees
Obstetricians
Birthing Facilities
Financial Realities
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Provider Trainee Survey 10
Emory
Ob/Gyn Residents (N=95) 84.2% Response Rate (n=80)
CNM Students (N=28) 100% Response Rate (n=28)
37% 63%
High School
42%
58%
Medical School
Georgia
Elsewhere
91%
9%
Female
Male
Ob/Gyn Residents 11
82%
18%
Nursing School
Georgia
Elsewhere
25%
75%
High School
96%
4%
Female
Male
CNM Students 12
Emory
28% 28%
44%
0
5
10
15
20
25
30
35
40
45
Yes No Unsure
Staying in Georgia 13
32% 36%
32%
0
5
10
15
Yes No Unsure
Ob/Gyn Residents CNM Students
Will you stay in Georgia upon completion of your training?
Rural / Shortage Areas 14
Ob/Gyn Residents CNM Students
How likely are you to practice
in one of Georgia’s rural/shortage areas?
3%
22%
46%
29%
0
5
10
15
20
25
30
35
40
45
ExtremelyLikely
Likely Unlikely ExtremelyUnlikely
18%
36%
46%
0% 0
5
10
15
ExtremelyLikely
Likely Unlikely ExtremelyUnlikely
0
5
10
15
20
25
30
35
40
45
Likely Unlikely
Ob > Gyn
Ob < Gyn
No Preference
CNM Students
Practice Preference 15
Ob/Gyn Residents
How likely are you to practice
in one of Georgia’s rural/shortage areas?
p = 0.01 p = 0.06 0
5
10
15
Likely Unlikely
Ob > Gyn
Ob < Gyn
No Preference
Georgia Ties 16
Ob/Gyn Residents CNM Students
How likely are you to practice
in one of Georgia’s rural/shortage areas?
0
5
10
15
20
25
30
35
40
45
Likely Unlikely
GeorgiaTie(s)
No GeorgiaTie(s)
0
5
10
15
Likely Unlikely
GeorgiaTie(s)
No GeorgiaTie(s)
p = 0.13 p = 0.15
Debt Burden 17
CNM Students Ob/Gyn Residents
25% 25%
50%
0
5
10
15
20
25
30
35
40
45
≤$99,999 $100,000-199,000 ≥$200,000
71%
25%
4%
0
5
10
15
20
25
≤$99,999 $100,000-199,000 ≥$200,000
0
10
20
30
40
50
60
2006 2009 2012 Current
≤$99,999
$100,000-199,999
≥$200,000
Debt Trends: Residents 18
Georgia Board for Physician Workforce. GME Annual Survey, compiled data 2006-2012.
0
10
20
30
Likely Unlikely
With financialincentive
Withoutfinancialincentive
0
10
20
30
40
50
60
70
Likely Unlikely
With financialincentive
Withoutfinancialincentive
Financial Incentives 19
CNM Students Ob/Gyn Residents
How likely are you to practice
in one of Georgia’s rural/shortage areas?
p < 0.001 p < 0.001
Financial incentives include
loan repayment, tax credits,
guaranteed salary,
differential pay, support to
open own practice, and
higher Medicaid
reimbursement rates
Obstetricians
Quality of life
Demanding call schedules
Departure of other local physicians
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Moultrie “We are the only obstetrical
practice in town. With one
OB and a midwife, we did
550 deliveries last year.
Sometimes we see 60
women in a day. 75 to 80
percent of our patients are
Medicaid. It’s difficult to
recruit physicians of any
kind to this area.”
5 Waycross “There were only 2 OBs in
Waycross when I [left] the
state. They need 4 to
adequately take care of all the
women in the community.”
Birthing Facility Closures
Rural Hospitals
Labor & Delivery Units
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5 Waycross “In OB, you don’t want to be too
far from where you need to be.”
Labor &
Delivery
Closures
2012-2014
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Labor &
Delivery
Closures
1994-2015
40%
decline
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Financial Realities
Malpractice insurance
Retirement of obstetricians
Family practitioners avoiding maternity care
Medicaid reimbursement
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5 La Grange “The paperwork kept getting
more and more complicated [but]
the malpractice insurance rate
increase was the clincher. We
stopped OB.”
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Americus “In rural Georgia, 70-80% of
patients are Medicaid, and with
today’s reimbursement rates, no
matter how smart you run your
business, it’s hard to get by.”
Consequences
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Infant mortality:1 16th
Maternal mortality:2 2nd
1. National Women’s Law Center. www.hrc.nwlc.org.
2. Henry J. Kaiser Family Foundation. www.kff.org.
March of Dimes,
Premature Birth:1
Population Institute,
Reproductive Health:2
1. March of Dimes. 2014 Premature Birth Report Cards.
2. Population Institute. 2014 Reproductive Health and Rights Report Cards.
C-
D-
Perinatal Periods of Risk 33
CityMatCH. Perinatal Periods of Risk. www.citymatch.org.
Rural Disparities
Rural pregnant women are at increased risk of:
Late initiation of prenatal care1
Hospitalization for pregnancy complications1
Home birth1
Low birth weight2
Neonatal mortality2
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1. ACOG Committee Opinion 429. Obstet Gynecol, 2014.
2. Larson EH, et al. Univ. of Washington Rural Health Research Center, 2008.
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Americus “[From] Preston, it’s 30 miles to
Americus. If [patients] have
cars, they don’t have much
gas, and there’s no public
transportation. They don’t
come to prenatal care.”
5 Preterm Birth in Georgia
1999-2009
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5 5 5
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Are They Related?
Driving Time and Preterm Delivery
Controlled for maternal age, race/ethnicity, marital status, maternal education, government-assisted payment,
maternal residence, birth order, prior poor infant health outcome, and transfer status
Driving Time Odds Ratio for Preterm Delivery
(< 37 weeks), with 95% CI
≤ 15 minutes 1.00
16 – 30 minutes 1.06 (1.01, 1.11)
31 – 45 minutes 1.09 (1.03, 1.14)
> 45 minutes 1.53 (1.46, 1.60)
There is a spatial mismatch between
a pregnant woman’s risk and her access to services
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Driving Time and Preterm Delivery: Non-Metropolitan Georgia, 1999-2009
24% of pregnant women drove >45 minutes to access ob services
Women that drove >45 minutes were 1.5x more likely to deliver preterm
than women that drove <15 minutes
Average drive times
Woman that delivered preterm: 40 minutes
Woman that delivered at term: 32 minutes
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Potential
Solutions
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Potential Solutions to Crisis
Recruitment
Retention
Referral
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Recruitment
Past Success
Financial incentive programs: RPTC, PRAAP
Upcoming Challenges
GME slots
Applicants to medical school and residency training
South Georgia CNM training program
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Financial Incentive Programs
Rural Physician Tax Credit1
Georgia Department of Revenue
Tax credit: $5,000 annually for max. 5 years
Physicians for Rural Areas Assistance Program2
Georgia Board for Physician Workforce
Loan repayment: $25,000 annually, for max. 4 years or $100,000
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1. Georgia Dept. of Revenue. 560-7-8-.20: Rural Physician Credit, 2012.
2. Tucker C. PRAAP Application. Georgia Board for Physician Workforce, 2012.
Physicians for Rural Areas Assistance Program
(PRAAP)
House Bill 998 (2014)
HB 998 permits Georgia Board for Physician Workforce to
adapt qualification criteria for PRAAP
Program can now include counties that have populations
>35,000 but are still in need of obstetric providers
Passed March 2014
Signed into law April 2014
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Georgia General Assembly, 2014. House Bill 998.
Retention
Past Successes
Medicaid parity
Increased Medicaid reimbursement for ob codes
Upcoming Challenge
Medical liability reform
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Medicaid Parity
Initially absent from Governor’s proposed budget
Appropriations amended by General Assembly
House Bill 76 (2015)
$23 million (state) + ~ $46 million (federal) = full parity
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Georgia Budget & Policy Institute. Overview: 2016 Fiscal Year for the Department of Community Health.
Medicaid Reimbursement
First increase in Medicaid reimbursement in 14 years
Targeted codes for prenatal and peripartum care
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Procedure Code Possible Fee Increase
59400 – Obstetric Care $ 330
59425 – Antepartum Care Only $ 180
59426 – Antepartum Care Only $ 350
59510 – Cesarean Delivery $ 220
59610 – VBAC Delivery $ 360
59618 – Attempted VBAC Delivery $ 260
Patterson A. GOGS Newsletter, April 2015.
Referral
Past Success
Perinatal Regions and Centers
Upcoming Challenges
Improved regionalization
- Prenatal services
- Delivery hospitalization
Telemedicine
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Georgia Perinatal Regions and Centers
GOGS. Georgia’s Regional Perinatal System. www.gaobgyn.org.
Improving Regionalization
Prenatal services
Sweeping reform ?
Delivery hospitalization
Risk-appropriate care
Assessment of service capacity
- AAP neonatal levels of care1
- ACOG/SMFM maternal levels of care2
Role of telemedicine
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1. AAP Policy Statement. Pediatrics, 2012.
2. ACOG/SMFM Obstetric Care Consensus. AJOG, 2015.
Congressional Committees
2013: Joint Study Committee on Medicaid Reform
2014: House of Representatives Study Committee
on Medical Education
2015: Senate Study Committee on Women’s
Adequate Healthcare
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Summary
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Summary
Georgia has the 2nd highest maternal mortality and 16th highest infant mortality ratio in the U.S.
Outside of Atlanta, the obstetric provider shortage is severe and getting worse, and L&D units are rapidly closing
Women that drive long distances for obstetric care are at increased risk of adverse outcomes
The Georgia General Assembly has undertaken several initiatives to improve maternal and infant health in the state, but the efforts must continue …
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Acknowledgements
Georgia Maternal and Infant
Health Research Group
(GMIHRG)
Roger Rochat, MD
Andrew Dott, MD, MPH
Pat Cota, RN, MS
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References
American Academy of Pediatrics. Policy Statement: Levels of Neonatal Care. Pediatrics (2012); 130(3): 587-97.
American College of Obstetricians and Gynecologists. Committee Opinion Number 429: Health Disparities in Rural Women. Obstet Gynecol (2012); 123: 371.
American College of Obstetricians and Gynecologists / Society of Maternal-Fetal Medicine. Obstetric Care Consensus: Levels of Maternal Care. AJOG (2015); 212(3): 259-71.
Bluestein G. New Georgia abortion restrictions in doubt after judge’s ruling. Atlanta Journal Constitution. Dec 25, 2012. Accessed online July 27, 2015 at www.ajc.com.
CityMatCH. Perinatal Periods of Risk. Accessed online July 27, 2015 at www.citymatch.org.
General Assembly of Pennsylvania, 2014. Senate Bill 1456.
Georgia Board for Physician Workforce. Graduate Medical Education Annual Survey, compiled data from 2006-2012. Received from Colette Caldwell July 22, 2013.
Georgia Board for Physician Workforce. Physician Workforce Resource Center. Accessed online Oct 1, 2011 at www.gbpw.ga.gov.
Georgia Budget & Policy Institute. Overview: 2016 Fiscal Year for the Department of Community Health. Accessed online July 27, 2015 at www.gbpi.org.
Georgia Department of Revenue. 560-7-8-20: Rural Physician Credit. Accessed online Jan 1, 2012 at http://rules.sos.state.ga.us/docs/560/7/8/20.pdf.
Georgia General Assembly, 2012. House Bill 954.
Georgia General Assembly, 2014. House Bill 998.
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References
Georgia Obstetrical and Gynecologic Society. Georgia’s Regional Perinatal System. Accessed online July 27, 2015 at www.gaobgyn.org.
Henry J. Kaiser Family Foundation. State Health Facts, Infant Mortality Rate (2010). Accessed online March 13, 2015 at www.kff.org.
Larson EH, et al. Poor Birth Outcome in the Rural United States: 1985-1987 to 1995-1997. The University of Washington Rural Health Research Center; 2008.
March of Dimes. 2014 Premature Birth Report Cards. Accessed online July 27, 2015 at www.marchofdimes.com.
National Women’s Law Center. Making the Grade on Women’s Health: A National and State by State Report Card, Maternal Mortality Rate (2010). Accessed online March 13, 2015 at www.hrc.nwlc.org/states/georgia.
Ness CL and Cutler C. Mandating bad medicine. Philadelphia Inquirer. Accessed online July 28, 2014 at www.philly.com.
Patterson A. Georgia Legislation Gives OBGyns First Medicaid Increase in 14 Years. Georgia Obstetrical and Gynecologic Society Newsletter, April 2015.
Population Institute. 2014 Reproductive Health and Rights Report Cards. Accessed online July 27, 2015 at www.populationinstitute.org.
Rayburn WF and American Congress of Obstetricians and Gynecologists. The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications, 2011.
Tucker C. Application for Physicians for Rural Area Assistance Program, 2012. Georgia Board for Physician Workforce. Accessed online May 15, 2013 at www.gbpw.georgia.gov.
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