Over the past two years, an “ominous slippage” in the number of medical residents agreeing to practice in New Jersey — from 50 to 32 percent — could lead to increasingly severe shortages of primary care physicians and specialists by 2020, state teaching hospitals executives are warning.
That’s disturbing news for a state already hurting for doctors — especially those practicing family and internal medicine.
According to a study released earlier this year by the New Jersey Council of Teaching Hospitals, shortages are already acute in some parts of the state, including Ocean and Monmouth counties. New Jersey’s ratio of primary care doctors to patients currently is 36 percent below the national average. And Ocean County has the lowest ratio in the state — less than the half the state average— with a current unmet need of 83 family medicine physicians, according to the study.
Unfortunately, the situation seems destined to get worse in New Jersey and nationally. Between 1997 and 2005, the number of U.S. medical school graduates entering family practice residencies fell by 50 percent, as doctors opted for more lucrative specialties that offered more normal family lives.
The New Jersey study estimated there would be a shortage of 2,800 physicians statewide by 2020 — about 12 percent fewer than the projected need.
The shortfall nationally is estimated at 7.5 percent to 8.5 percent. The problem is at least partially self-inflicted, executives at teaching hospitals contend.
Other states are more aggressive in helping doctors launch practices, said J. Richard Goldstein, president of the state Council of Teaching Hospitals and an internist with a practice in Middlesex County.
“To put it simply: They offer richer loan-repayment programs, better Medicaid rates, caps on pain and suffering, lower tax burdens, prompter pay laws for HMOs, less red tape. These states have rolled out the welcome carpet,” Goldstein said.
Not only that, observed the council’s 2009 New Jersey Resident Exit Survey Final Report, other states offer more jobs for doctors’ spouses and better weather.
At the same time, the addition of thousands of newly insured persons, thanks to federal health reform legislation, could make the shortage even worse, doctors said.
Medical centers across the state already are feeling the effects.
It took seven years for The Children’s Hospital at Monmouth Medical Center in Long Branch to fill an open pediatric surgeon’s slot, said Dr. Margaret Fisher, a pediatric infectious disease specialist and director of The Children’s Hospital. And it took four years to fill a second slot for a pediatric specialist, she said.
The hospital lacks enough outside funding to maintain fellowships that allow residents to continue their education in hospitals after they complete their residency, she said.
A lack of fellowships is among the reasons why only 32 percent of 2009 medical residents training in New Jersey hospitals say they planned to practice medicine in New Jersey.
Taken together, the advantages offered by other states make it easier for new doctors to establish a practice and to out-earn New Jersey doctors.
A primary care physician can make $40,000 more per year in Florida ($190,000 vs. $150,000) than in New Jersey, said Dr. Jack Bucek, director of the Somerset Family Medicine Residency Program at Somerset Medical Center in Somerville. Throw in Florida’s lower cost of living and the gap becomes even greater.
In 2008, Bucek was able to retain just three of the seven annual residents in his program. In 2009, he lost all of them to out-of state practices.
The 2009 report showed a “significant drop” in residents staying in New Jersey, said Deborah Briggs, a vice president with the teaching hospitals council. In three previous annual exit surveys, she said, 47 percent to 50 percent of the residents who responded to the survey said they would practice in New Jersey, Briggs said.
New Jersey’s 32 percent 2009 retention rate is well below the national average of 47 percent, and the rate in New York, 46 percent, or Pennsylvania, 42 percent.
“This slippage is ominous,” Goldstein wrote in the survey’s introduction. “When the 2008 rate slipped to 47 percent, New Jersey was concerned, but this year we reached an alarming point where only 32 percent, less than one in every three residents, intend to establish a practice in the state.”
Facing the same doctor drain, Texas in 2003 imposed a cap on malpractice pain and suffering awards, streamlined regulations and created a system that spurs prompt insurance company payments to physicians — actions that reversed a long decline in the number of Texas trained physicians staying home and attracted a growing number of out-of-state doctors, Briggs said.
Cost-of-living issues hobble residents more than undergraduates studying medicine, said Dr. Susan Kaye, chairwoman of the Department of Family Medicine at Overlook Hospital in Summit and medical director of academic affairs for Atlantic Health Systems, which includes Morristown Memorial Hospital.
Residents tend to be older, have started families and have different housing needs, she said. Many face the double challenge of buying a house and repaying their education debt, which ranges from $100,000 to $500,000 and averages about $250,000.
As a result, Kaye said, graduates from the Atlantic Health residency program are ending up in New York, Pennsylvania and even Kansas—more favorable environments for starting a medical practice, she said.
For some residents, not even family ties can keep them in New Jersey. Kaye said one former Atlantic Health resident settled in Colorado to practice medicine even though his family was in New Jersey. The doctor said he could fly back and visit his family a couple of times a year, but would make more money in Colorado.
Like any small business, doctors setting up practice in New Jersey face high real estate prices and property taxes, said Dr. Ted Louie, an internist with a practice in East Brunswick and president of the Medical Society of Middlesex County.
In addition, Louie said, doctors have to buy practice- related equipment, such as an electronic record- keeping system, which can cost up to $10,000, according to industry figures.
The cost of medical malpractice insurance has not been fully addressed in New Jersey, Louie said. In 2008, the state created a $16 million pool to provide insurance help for 1,200 obstetricians, neurosurgeons and radiologists, but other practitioners still are waiting for relief, he said.
Sen. Joseph Vitale, D Middlesex, said part of the problem in attracting family medical practitioners is the income differential between family practitioners and specialists. Vitale said he asked a class of 80 medical students at Rutgers two years ago how many planned to enter family practice and only two hands went up.
Another problem, according to Vitale, is that many New Jersey high school graduates settle in other states after attending colleges there.
A continuing cost issue is the rate of Medicaid reimbursement, said Dr. Joseph Reichman of Camden, president of the Medical Society of New Jersey.
New Jersey has the lowest Medicaid reimbursement rates in the country. This is especially evident for specialists, Reichman said. A pediatric surgeon in New Jersey, for instance, might be reimbursed as little as $30 for lung surgery to correct an acute respiratory problem — lower than in other states.
The teaching hospitals council said that increasing New Jersey’s Medicaid
fee rates to the national average — a $56 million proposition — would be a place to start. Since Medicaid is a joint program of state and local governments, New Jersey would have to pay $28 million to receive a matching federal payment of $28 million.
What can be done to halt doctor drain?
The New Jersey Council of Teaching Hospitals offers several recommendations to stem the tide of medical residents leaving the state:
1. Create an organization to monitor, forecast, predict and refine recommendations to ensure an adequate and well-dispersed supply of physicians and advanced practitioners.
2. Expand retention and recruitment initiatives to encourage physicians to enter, remain or return to practice in New Jersey. Examples include:
-- Expansion of the current loan redemption program.
-- Creation of a recruitment website.
-- Establishment of a three-year tax forgiveness, practice subsidy fund and mortgage assistance program.
-- Expansion of pipeline programs in grades K to 12 that motivate New Jersey residents for medical careers.
3. Align goals and incentives of medical schools, teaching hospitals and state government. Goals include:
-- Identify, target and enroll medical school students who will more likely practice in New Jersey.
-- Establish incentive grants for medical schools and teaching hospitals that encourage them to retain their graduates.
-- Develop a curriculum that reinforces team based care and allows the state to apply for federal grants.
4. Enhance state funding for medical education and post-graduate residency programs. New Jersey graduate medical education cost $765 million in 2007. State Medicaid graduate residency education funds covered $60 million; Medicare funds covered $340 million and the rest was paid for by hospitals through foundation grants and operational funds.
5. Pursue federal reforms to address systemic problems in graduate medical education programs, administrative processes and regulatory oversight.
Physician Workforce Report