In 2002, the chair of the American Academy
of Pediatrics Section on Pediatric Rheumatology
called for a doubling of the number of
United States pediatric rheumatologists
to 400. 23
The appropriateness of this goal has yet
to be evaluated and depends, in part,
on the geographic distribution of pediatric
rheumatologists and patient demand for
pediatric rheumatology care. Moreover,
academic medical centers continue to be
the primary employers of pediatric rheumatologists;
as such, the educational and research
needs of these institutions heavily influence
the demand for these providers.
Patient Demand
for Pediatric Rheumatology Care by State
Estimating demand for pediatric rheumatology
care is challenging. Because of low incidence
rates, national sample surveys of the
general population generally fail to identify
sufficient patients with juvenile rheumatic
diseases to generate reliable estimates.
Using an exhaustive list of 48 possible
International Classification of Disease
(ICD-9) codes, the National Ambulatory
Medical Care Survey (NAMCS) contains only
16 records for rheumatic diseases visits
among children under 18. National Hospital
Ambulatory Care Survey (NHAMCS) similarly
contains 57 visit records for rheumatic
conditions among children under 18. As
a result, reliable estimates of patient
demand for care are not possible using
such data.
In the absence of a measure of need for
pediatric rheumatology services or even
utilization of these services, prevalence
rates [iii]
allow estimates of patient to provider
ratios as a proxy for patient demand.
Using state-level population data from
the Bureau of the Census 24
and physician data from the American College
of Rheumatology (ACR) Membership File
and American Board of Pediatrics (ABP)
Diplomate File, ratios of pediatric population
to pediatric rheumatologists were generated
for each State. State level ratios were
used because many States have either no
pediatric rheumatologist or only one pediatric
rheumatologist. As such, a state-level
analysis helps identify relatively underserved
States and provides an estimate of the
number of pediatric rheumatologists that
are needed nationwide. As in analyses
of the MSA-level ratios, these estimates
rely on “head counts” and do not adjust
for the percentage of time that a pediatric
rheumatologist is involved in patient
care as these data are not available for
each pediatric rheumatologist in the United
States.
Table
9: Ratio of Pediatric Population to Board-Certified
Pediatric Rheumatologists, 2003 American
Board of Pediatrics Diplomate File
0 |
350,464 |
N/A |
N/A |
8 |
3,181,338 |
397,667 |
1,551 |
2 |
1,528,991 |
764,496 |
2,982 |
1 |
719,685 |
719,685 |
2,807 |
3 |
698,637 |
232,879 |
908 |
2 |
965,528 |
482,764 |
1,883 |
4 |
1,190,001 |
297,500 |
1,160 |
0 |
290,439 |
N/A |
N/A |
7 |
1,309,432 |
187,062 |
730 |
11 |
1,468,554 |
133,505 |
521 |
7 |
2,561,139 |
365,877 |
1,427 |
5 |
1,271,850 |
254,370 |
992 |
1 |
752,866 |
752,866 |
2,936 |
7 |
1,399,492 |
199,927 |
780 |
0 |
223,819 |
N/A |
N/A |
1 |
443,800 |
443,800 |
1,731 |
0 |
491,476 |
N/A |
N/A |
0 |
304,436 |
N/A |
N/A |
4 |
2,003,204 |
500,801 |
1,953 |
1 |
495,612 |
495,612 |
1,933 |
15 |
4,440,924 |
296,062 |
1,155 |
4 |
1,940,947 |
485,237 |
1,892 |
0 |
160,092 |
N/A |
N/A |
12 |
2,844,071 |
237,006 |
924 |
3 |
882,062 |
294,021 |
1,147 |
2 |
827,501 |
413,751 |
1,614 |
9 |
2,852,520 |
316,947 |
1,236 |
1 |
241,180 |
241,180 |
941 |
0 |
955,930 |
N/A |
N/A |
Table
9: Ratio of Pediatric Population to Board-Certified
Pediatric Rheumatologists, 2003 American
Board of Pediatrics Diplomate File, cont.
Ratios were calculated separately using
the ACR and ABP files; States without
pediatric rheumatology providers are highlighted
in yellow in Tables 9 and 10. Using the
ABP file, Washington D.C. [iv]
has the lowest ratio of children to pediatric
rheumatologists at 47,645:1; Texas has
the highest with a ratio of 953,206:1
(Table 9). Assuming a prevalence of pediatric
rheumatic conditions of 390 per 100,000
children, ratios range from 186 children
with rheumatic disease per provider in
Washington D.C. to 3,718:1 in Texas. Among
States that lack Board-certified pediatric
rheumatologists, the population size ranges
from 126,000 in Wyoming to over 1.3 million
in Arizona.
Table 10: Ratio of
Pediatric Population to Self-identified
Pediatric Rheumatologists, 2003 American
College of Rheumatology
Table 10: Ratio of Pediatric Population
to Self-identified Pediatric Rheumatologists1,
2003 American College of Rheumatology
(continued)
|
South
Dakota |
0 |
198,037 |
N/A |
N/A |
Tennessee |
3 |
1,340,930 |
446,977 |
1,743 |
Texas |
6 |
5,719,234 |
953,206 |
3,718 |
Utah |
2 |
707,366 |
353,683 |
1,379 |
Vermont |
1 |
139,346 |
139,346 |
543 |
Virginia |
6 |
1,664,810 |
277,468 |
1,082 |
Washington |
6 |
1,486,340 |
247,723 |
966 |
Washington,
DC |
1 |
95,290 |
95,290 |
372 |
West
Virginia |
0 |
403,481 |
N/A |
N/A |
Wisconsin |
5 |
1,348,268 |
269,654 |
1,052 |
Wyoming |
0 |
126,807 |
N/A |
N/A |
1 Excludes trainees
and physicians who are not involved in
patient care
The ratios change slightly using the
ACR data on Board-certified pediatric
rheumatologists. The ratio of the pediatric
population to pediatric rheumatology providers
ranges from a low of 91,225:1 in Delaware
to a high of 953,206:1 in Texas (Table
9). In terms of the number of children
with rheumatic diseases per provider,
these ratios translate into approximately
356 children with rheumatic diseases per
pediatric rheumatologist in Delaware to
3,718 children with rheumatic diseases
per pediatric rheumatologist in Texas.
Three States that lack Board-certified
pediatric rheumatologists have pediatric
populations in excess of 950,000; the
remaining 10 States have pediatric populations
of fewer than 500,000.
Projected Need
for Pediatric Rheumatologists
Previous studies of physician market
entry have assumed that the population
size needed to support a physician entrant
increases with the level of specialization.
25
One model estimated, for example, that
the population needed to attract the first
family practice physician to an area is
3,300; in contrast, a population of 69,000
was needed to attract the first cardiologist
to a market area. This study also showed
that the population increments needed
to attract additional providers were smaller
than the population needed to attract
the first provider.
Table 11: Estimated
Number of Pediatric Rheumatologists Needed
by State
|
Alabama |
0 |
1,066,177 |
5 |
5 |
-5 |
Alaska |
0 |
196,825 |
0 |
0 |
0 |
Arizona |
0 |
1,334,564 |
6 |
6 |
-6 |
Arkansas |
2 |
660,224 |
3 |
3 |
-1 |
California |
22 |
8,923,423 |
44 |
44 |
-22 |
Colorado |
2 |
1,065,510 |
5 |
5 |
-3 |
Connecticut |
4 |
828,260 |
4 |
4 |
0 |
Delaware |
2 |
182,450 |
0 |
2 |
0 |
Florida |
7 |
3,569,878 |
18 |
18 |
-11 |
Georgia |
3 |
2,056,885 |
10 |
10 |
-7 |
Hawaii |
2 |
289,340 |
1 |
2 |
-1 |
Idaho |
0 |
350,464 |
2 |
2 |
-2 |
Illinois |
7 |
3,181,338 |
16 |
16 |
-9 |
Indiana |
2 |
1,528,991 |
7 |
7 |
-5 |
Iowa |
1 |
719,685 |
3 |
3 |
-2 |
Kansas |
2 |
698,637 |
3 |
3 |
-1 |
Kentucky |
2 |
965,528 |
5 |
5 |
-3 |
Louisiana |
3 |
1,190,001 |
6 |
6 |
-3 |
Maine |
0 |
290,439 |
1 |
1 |
0 |
Maryland |
6 |
1,309,432 |
6 |
6 |
0 |
Massachusetts |
7 |
1,468,554 |
7 |
7 |
0 |
Michigan |
7 |
2,561,139 |
13 |
13 |
-6 |
Minnesota |
4 |
1,271,850 |
6 |
6 |
-2 |
Mississippi |
1 |
752,866 |
4 |
4 |
-3 |
Missouri |
5 |
1,399,492 |
7 |
7 |
-2 |
Montana |
0 |
223,819 |
0 |
0 |
0 |
Nebraska |
1 |
443,800 |
2 |
2 |
-1 |
Nevada |
0 |
491,476 |
2 |
2 |
-2 |
New
Hampshire |
0 |
304,436 |
1 |
1 |
-1 |
New
Jersey |
6 |
2,003,204 |
10 |
10 |
-4 |
New
Mexico |
1 |
495,612 |
2 |
2 |
-1 |
New
York |
11 |
4,440,924 |
22 |
22 |
-11 |
North
Carolina |
4 |
1,940,947 |
9 |
9 |
-5 |
North
Dakota |
0 |
160,092 |
0 |
0 |
0 |
Ohio |
10 |
2,844,071 |
14 |
14 |
-4 |
Oklahoma |
3 |
882,062 |
4 |
4 |
-1 |
Oregon |
2 |
827,501 |
4 |
4 |
-2 |
Pennsylvania |
8 |
2,852,520 |
14 |
14 |
-6 |
Rhode
Island |
1 |
241,180 |
0 |
1 |
0 |
South
Carolina |
0 |
955,930 |
5 |
5 |
-5 |
South
Dakota |
0 |
198,037 |
0 |
0 |
0 |
Tennessee |
3 |
1,340,930 |
6 |
6 |
-3 |
Texas |
6 |
5,719,234 |
28 |
28 |
-22 |
Utah |
2 |
707,366 |
3 |
3 |
-1 |
Vermont |
1 |
139,346 |
0 |
1 |
0 |
Virginia |
6 |
1,664,810 |
8 |
8 |
-2 |
Washington |
6 |
1,486,340 |
7 |
7 |
-1 |
Washington,
DC |
1 |
95,290 |
0 |
1 |
0 |
West
Virginia |
0 |
403,481 |
2 |
2 |
-2 |
Wisconsin |
5 |
1,348,268 |
6 |
6 |
-1 |
Wyoming |
0 |
126,807 |
0 |
0 |
0 |
1 Excludes trainees and physicians
not currently involved in patient care
One previous report has suggested that
a total population base of 1 million is
needed to provide sufficient patient demand
for a pediatric rheumatologist; 19
therefore, estimates presented here
use this population size as a starting
point. Given that children represent approximately
25 percent of the United States population,
a pediatric population of 250,000 was
used as a threshold for identifying States
that could support their first pediatric
rheumatologist. Since a previous study
has shown that the population increment
needed to attract the second provider
is smaller than the population size needed
to attract the initial provider, 25
the model assumed that each additional
pediatric population increment of 200,000
could support an additional pediatric
rheumatologist. The results that presented
here used State level data from the ACR;
however, the calculations using ABP data
are comparable.
Assuming that a pediatric population
of 250,000 is needed to support a pediatric
rheumatologist, 9 of the 13 States that
currently lack a Board certified pediatric
rheumatologist could generate enough demand
to support a pediatric rheumatologist.
As Table 11 shows, the population under
age 18 in Alaska, North Dakota, South
Dakota, and Wyoming are below the 250,000
threshold and, therefore, may not generate
sufficient patient demand to support a
pediatric rheumatologist. However, combined
regions, such as North and South Dakota
may be able to support a pediatric rheumatologist.
Assuming that entry continues with an
additional rheumatologist for each additional
200,000 children, a minimum of 331 rheumatologists
would be needed in the United States.
Table 10 shows that several States, especially
those with training programs, have more
pediatric rheumatologists than are “needed”
based on population size. Many of these
providers may be primarily involved in
research and teaching, creating a situation
in which “head counts” lead to an overestimate
of actual supply. If one allows States
with training programs to have more rheumatologists
than are clinically needed based on population
size and considers the current supply
per State as a minimum, the number of
rheumatologists needed nationwide is 337.
The 250,000 threshold, however, may be
unreasonably high. Given a prevalence
rate of 390 per 100,000, this threshold
translates into 975 children with rheumatic
diseases per rheumatologist. Given the
multitude of needs that characterize this
patient population, it is unlikely that
one rheumatologist could care for nearly
1,000 patients. A previously unpublished
survey of pediatric rheumatology programs
found that the average number of children
seen annually by each pediatric rheumatology
unit was 443. [v]
Only 12 percent of pediatric rheumatology
units, including those with multiple providers,
saw more than 1,000 children a year.
Therefore, the actual number of patients
that a pediatric rheumatologist is able
to treat may be far lower than 975. These
estimates easily allow the use of different
population thresholds or prevalence rates
to estimate the pediatric rheumatology
workforce requirements.
Estimates of pediatric rheumatology workforce
requirements should also consider the
roles of internist rheumatologists and
primary care providers (PCPs) in caring
for this population. The role of PCPs
appears to be very limited, especially
for diagnosis, initial management, and
refractory cases. While PCPs may be able
to extend pediatric rheumatologists by
managing or co-managing mild cases, their
role is likely to be limited by the small
number of cases in which they are involved.
Past research has shown, conversely,
that internist rheumatologists figure
prominently in the care of children with
rheumatic diseases 4,
6, 21,
22
and may provide nearly one-half of the
care to children under age 18 with rheumatic
diseases. 22
There is also evidence that the involvement
of internist rheumatologists is largely
due to the lack of available pediatric
rheumatology providers. The quality of
care provided by internist rheumatologists
to children with rheumatic diseases and
the extent to which they adequately substitute
for pediatric rheumatologists remains
unknown and has important implications
for the supply of pediatric rheumatologists.
The role of pediatric and internist rheumatologists
is discussed in greater detail in Chapter
IV.
Open Positions and
Salary Concerns
In September 2004, the “Job Openings”
page of the American Academy of Pediatrics
Rheumatology Section 26
listed 25 advertised positions at 21 institutions
or practices. Of the 23 positions in
academic medical centers, one was at the
level of division chair; 9 at the level
of full, associate, or assistant professor;
7 positions of unspecified rank; and 6
research positions, some of which were
also open to non-physician researchers;
2 positions were in private practice.
A few of the listings suggest a level
of desperation at the recruiting institutions.
A listing from Tennessee reads:
“… We would prefer someone who does
research, who would be willing to do
some clinical but could have protected
time. We are open, however, to considering
any Pediatric Rheumatologist who might
be interested. They would become the
second pediatric rheumatologist.”
Another from Plano, TX describes an area
with particularly constrained access:
“The nearest, and only, pediatric
rheumatologist is in Dallas and serves
both the Dallas and Fort-Worth cities.
The next nearest pediatric rheumatologists
are in Oklahoma City and Houston, both
are more than two hours away. As a result,
this one rheumatologist in Dallas has
over a six-month waiting list. The practice
is in a well-established hospital that
specializes in high quality medical
care, with the largest private practice
neonatal intensive care unit in the
area. The hospital has a significant
pediatric staff (over 40), and all pediatric
sub-specialists. A significant demand
for pediatric rheumatology exists in
this area and at the hospital. The hospital
and community are making a very good
offer for the qualified applicant.”
While not all advertised positions were
at the entry level, it is safe to assume
that positions vacated by senior faculty
would need to be filled by either another
senior pediatric rheumatologist or a newly
graduated fellow. As noted in the previous
chapter, only 10 pediatric rheumatology
fellows entered their final year of training
in 2003. One expects, therefore, that
these 10 fellows were available on the
job market in July 2004. Given that 23
positions were open in September 2004,
there appears to be either excess demand
for, or a shortage of, pediatric rheumatologists.
Geographic Distribution
of Recently Graduated Pediatric Rheumatologists
The practice location decisions of recent
pediatric rheumatology fellowship graduates
provide important insights into the persistent
tendency for these physicians to locate
in certain areas. Using 2003 diplomate
data from the ABP file, physicians Board
certified in pediatric rheumatology who
graduated from medical school after January
1, 1987 were classified as “recent” graduates
(n=55); allowing for 16 years for physicians
to complete residency and fellowship and
to certify; all others were classified
as non-recent graduates. Graduation date
was used to classify diplomates rather
than certification date because the first
certifying exam in pediatric rheumatology
was not offered until 1992. These data
were used to study the practice locations
of recent graduates.[vi]
Over 80 percent of recent diplomates
practice in a county that also has at
least one non-recent pediatric rheumatology
diplomate (Table 12). Only eight United
States counties currently have a pediatric
rheumatologist who recently graduated
but no pediatric rheumatologists who graduated
prior to 1987: Johnson, IA (city: Iowa
City); Hampden, MA (city: Chicopee);
Norfolk, MA (City: Norwood); Livingston,
MI (City: Brighton); Jackson, MO (city:
Kansas City) [vi]
i; Multnomah, OR (City: Portland);
Providence, RI (city: Providence) and
Dane, WI (City: Madison). These data
suggest that the geographic distribution
of pediatric rheumatologists may remain
unchanged without incentives to practice
in underserved areas.
Table 12: Board-Certified
Pediatric Rheumatologists by County and
Graduation Cohort, American Board of Pediatrics,
2003
Arkansas |
Pulaski |
1 |
0 |
1 |
California |
Fresno |
2 |
1 |
1 |
|
Los
Angeles |
4 |
1 |
3 |
|
Orange |
2 |
1 |
1 |
|
San
Bernardino |
1 |
0 |
1 |
|
San
Diego |
2 |
0 |
2 |
|
San
Francisco |
3 |
1 |
2 |
|
San
Mateo |
1 |
0 |
1 |
|
Santa
Clara |
3 |
0 |
3 |
Colorado |
Denver |
2 |
1 |
1 |
Connecticut
|
Fairfield |
1 |
0 |
1 |
|
Hartford |
1 |
0 |
1 |
|
New
Haven |
2 |
0 |
2 |
Delaware |
New
Castle |
2 |
1 |
1 |
Florida |
Alachua |
2 |
0 |
2 |
|
Palm
Beach |
2 |
1 |
1 |
|
Pinellas |
3 |
1 |
2 |
Georgia |
Dekalb |
1 |
0 |
1 |
|
Fulton |
1 |
0 |
1 |
|
Richmond |
1 |
0 |
1 |
Hawaii |
Honolulu |
3 |
1 |
2 |
Illinois |
Cook |
8 |
1 |
7 |
Indiana |
Marion |
2 |
1 |
1 |
Iowa |
Johnson |
1 |
1 |
0 |
Kansas |
Wyandotte |
3 |
1 |
2 |
Kentucky |
Fayette |
1 |
0 |
1 |
|
Jefferson |
1 |
0 |
1 |
Louisiana |
Jefferson |
2 |
1 |
1 |
|
Orleans |
1 |
0 |
1 |
Maryland |
Baltimore
City |
1 |
0 |
1 |
|
Howard |
1 |
0 |
1 |
|
Montgomery |
5 |
1 |
4 |
Massachusetts |
Hampden |
2 |
2 |
0 |
|
Middlesex |
4 |
3 |
1 |
|
Norfolk |
1 |
1 |
0 |
|
Suffolk |
3 |
0 |
3 |
Michigan |
Kalamazoo |
1 |
0 |
1 |
|
Livingston |
1 |
1 |
0 |
|
Washtenaw |
5 |
2 |
3 |
Minnesota |
Hennepin |
3 |
1 |
2 |
|
Olmsted |
2 |
0 |
2 |
Mississippi |
Hinds |
1 |
0 |
1 |
Table 12: Board-Certified Pediatric
Rheumatologists by County and Graduation
Cohort American Board of Pediatrics, 2003,
cont.
Missouri |
Boone |
2 |
0 |
2 |
|
Jackson |
1 |
1 |
0 |
|
St.
Louis |
4 |
3 |
1 |
Nebraska |
Douglas |
1 |
0 |
1 |
New
Jersey |
Bergen |
2 |
0 |
2 |
|
Essex |
2 |
1 |
1 |
New
Mexico |
Bernalillo |
1 |
0 |
1 |
New
York |
Erie |
1 |
0 |
1 |
|
Monroe |
1 |
0 |
1 |
|
Nassau |
2 |
1 |
1 |
|
New
York |
9 |
5 |
4 |
|
Onondaga |
1 |
0 |
1 |
|
Westchester |
1 |
0 |
1 |
North
Carolina |
Durham |
2 |
0 |
2 |
|
Orange |
1 |
0 |
1 |
|
Pitt |
1 |
0 |
1 |
Ohio |
Cuyahoga |
3 |
2 |
1 |
|
Franklin |
2 |
0 |
2 |
|
Hamilton |
7 |
4 |
3 |
Oklahoma |
Oklahoma |
2 |
0 |
2 |
|
Tulsa |
1 |
0 |
1 |
Oregon |
Multnomah |
2 |
2 |
0 |
Pennsylvania |
Allegheny |
1 |
0 |
1 |
|
Chester |
1 |
0 |
1 |
|
Dauphin |
2 |
1 |
1 |
|
Philadelphia |
5 |
2 |
2 |
Rhode
Island |
Providence |
1 |
1 |
0 |
Tennessee |
Davidson |
2 |
0 |
2 |
|
Shelby |
1 |
0 |
1 |
Texas |
Dallas |
2 |
0 |
2 |
|
Harris |
4 |
0 |
4 |
Utah |
Salt
Lake |
2 |
1 |
1 |
Vermont |
Chittenden |
1 |
0 |
1 |
Virginia |
Albemarle |
1 |
0 |
1 |
|
Henrico |
2 |
0 |
2 |
|
Norfolk
City |
1 |
0 |
1 |
|
Richmond
City |
1 |
0 |
1 |
|
Roanoke |
1 |
0 |
1 |
Washington |
King |
5 |
2 |
3 |
Washington,
DC |
District
Of Columbia |
2 |
0 |
2 |
Wisconsin |
Brown |
1 |
0 |
1 |
|
Dane |
1 |
1 |
0 |
|
Milwaukee |
3 |
2 |
1 |
Summary
Given the size of the pediatric population
and the number of providers in each State,
it appears that a number of States have
rheumatologist to patient ratios that
exceed typical pediatric rheumatology
practice capacity. It is estimated that
60 percent of States have more than 1,000
children with rheumatic diseases per pediatric
rheumatologist. Assuming that a pediatric
population of 250,000 is needed to attract
an initial provider and increments of
200,000 are needed to attract additional
providers, it is estimated that a minimum
of 337 pediatric rheumatologists is needed
nationwide. Thus, there is a national
deficit of approximately 135 to 145 providers.
Furthermore, the number of trainees completing
fellowship is less than the number of
advertised positions. Thus, there is
considerable evidence that the current
supply of rheumatologists is not adequate
to meet employer demand and results in
a distribution of providers that limits
access for a substantial segment of the
pediatric population.
Practice location analyses of certified
pediatric rheumatologists demonstrate,
however, that 80 percent of recently trained
pediatric rheumatologists (i.e., those
who completed medical school in or after
1987) practice in a county that also has
an older pediatric rheumatologist. These
results suggest that newly trained rheumatologists
are not necessarily entering underserved
areas.
|