There are three major issues that present
significant challenges to both the short
and long-term ability of the pediatric
rheumatology workforce to meet the demand
for patient care. They are: (1) lack
of faculty and training availability;
(2) insufficient clinical care cost recovery;
and (3) research requirements limiting
patient care access.
Issue 1:
Lack of Faculty and Training Availability
There are currently 80 medical schools
in the United States with a pediatric
rheumatologist on faculty, leaving over
one-third of the Nation’s 125 medical
schools without physicians in this subspecialty.19
A shortage of these providers not only
limits the ability of these institutions
to care for children with rheumatic diseases,
but it leaves many medical schools and
pediatric residency programs unable to
adequately expose trainees to the pediatric
rheumatology field. Limited exposure to
pediatric rheumatology during medical
training intensifies the effects of the
pediatric rheumatology shortage in two
important ways:
- Leaving general pediatricians and
family physicians ill-prepared to be
involved in the initial diagnosis and
management of children with suspected
or known rheumatic diseases, thereby
increasing demand for pediatric rheumatologists,
and
- Decreasing the pool of students interested
in pursuing a career in this field.
As discussed in Chapter IV, past studies
have shown that having training in the
care of children with rheumatic diseases
may enhance providers’ willingness
to care for children with rheumatic disease.
One previous study found a relationship
between adequacy of training and referral
patterns for JRA among primary care providers;
consequently, pediatric rheumatology training
is particularly relevant to prepare primary
care physicians and pediatricians to identify
children with rheumatic diseases and participate
in their care.
Exposure to pediatric rheumatology is
also important during training because
of its effects on career choice. Studies
also found an association between exposure
to a subspecialty during training and
intentions to pursue it as a career.9,
32,
33
Since pediatric rheumatologists must first
complete medical school and pediatric
residency training before entering a pediatric
rheumatology fellowship, exposure to pediatric
rheumatology at earlier stages of physician
training may generate their interest in
the field.
Availability
of Pediatric Rheumatology Training in
General Pediatrics Programs
In the spring of 2004, all 195 pediatric
residency directors in the United States
and Puerto Rico were surveyed to assess
the status of pediatric rheumatology training
in general pediatric residency programs.
The survey questioned (1) the availability
of pediatric rheumatology training in
general pediatrics residency, (2) the
relationship between the characteristics
of pediatric rheumatology training in
general pediatrics residency and the presence
of pediatric rheumatologists at the training
institution, and (3) the adequacy of pediatric
rheumatology supply locally and statewide.
Details about the survey are provided
in Appendix F.
Of the 195 programs surveyed, 127 (65
percent) responded. Descriptive statistics
are presented in Table 17. Respondents
were asked to indicate the number of pediatric
rheumatologists with patient care responsibilities
at their institution. Seventy of the
responding programs (56.7 percent) had
one or more pediatric rheumatologists
on staff, including two institutions that
reported sharing a provider with another
institution. The number of pediatric
rheumatologists in these programs ranged
from one to six, with a mean of 1.8.
Programs with pediatric rheumatologists
on staff were significantly larger, in
terms of pediatric residents, than those
without these providers and had significantly
fewer residents pursuing general pediatrics
careers. Thus, pediatric rheumatologists
are located at larger, more academically-oriented
training programs.
Table
17: Characteristics of Responding Pediatric
Residency Programs, 2004 Survey of Program
Directors
Number
of Years Program in Existence |
32.2 |
28.2 |
35.1% |
Number
of General Pediatrics Residents |
41.1 |
29.9 |
49.6% |
Any
Internal Medicine (IM)/Pediatrics
Residents |
59.6 |
59.5 |
59.7% |
Number
of IM/Pediatrics Residentsa |
15.5 |
12.2 |
17.6% |
Any
Combined Pediatrics Residents |
15.6 |
9.5 |
19.4% |
Number
of Other Combined Pediatrics Residentsb |
4.9 |
2.5 |
5.7% |
Pediatric
Rheumatologist on Staff at Affiliated
Institution |
Yes |
56.7 |
N/A |
N/A |
No |
43.3 |
N/A |
N/A |
Percent
of Graduates in Primary Care |
Less than 25 |
0.0% |
0.0% |
0.0% |
26 to 50 |
26.0% |
10.9% |
37.5% |
51 to 75 |
58.3% |
70.9% |
48.6% |
More than 75 |
15.8% |
18.2% |
13.9% |
Percent
of Programs with a Pediatric Rheumatology
Rotation |
On-site Rotation Available |
57.5% |
9.1% |
94.4% |
"Away" Rotation Available |
22.0% |
45.4% |
4.2% |
No Rotation Available |
20.5% |
45.4% |
1.4% |
a Among those programs with
any Internal Medicine/Pediatric Residents
b Among those programs with
any Combined Pediatric Residents
Residency directors also were asked if
their program offered a pediatric rheumatology
rotation, either on-site or as an away
elective; overall, 57.5 percent of programs
offered a rotation on-site and an additional
22 percent offered a rotation as an away
elective (Table 18). Over 90 percent
of residency programs with a pediatric
rheumatologist on staff reported offering
a pediatric rheumatology rotation on-site.
Among those programs without a pediatric
rheumatologist on staff, 9 percent offered
a pediatric rheumatology rotation on-site
and 45 percent offered the rotation as
an away elective. Forty-five percent
of programs without a pediatric rheumatologist
on staff did not offer a pediatric rheumatology
rotation.
Table
18: Characteristics of Pediatric Residency
Training by Availability of a Pediatric
Rheumatology Rotation, 2004 Survey of
Program Directors
Percent
of Graduates in Primary Care** |
26% to 50% |
26.0 |
35.6 |
17.9 |
7.7 |
51% to 75% |
58.3 |
52.1 |
53.6 |
80.8 |
75% or more |
15.8 |
12.3 |
28.6 |
11.5 |
Percent
of General Pediatrics Residents
Doing a Pediatric Rheumatology Rotation |
None |
15.1 |
1.4 |
0.0 |
72.0 |
Less then 10% |
33.3 |
20.6 |
71.4 |
28.0 |
10 to 25% |
22.2 |
27.4 |
28.6 |
0.0 |
26% to 50% |
15.1 |
26.0 |
0.0 |
0.0 |
51% to 75% |
7.1 |
12.3 |
0.0 |
0.0 |
76% or More |
4.8 |
8.2 |
0.0 |
0.0 |
All, it is required |
2.4 |
4.1 |
0.0 |
0.0 |
Percent
of Programs by Type of Physicians
Involved in Rotationa |
On-site Pediatric Rheumatologist*** |
55.1 |
91.8 |
10.7 |
|
Off-site Pediatric Rheumatologist*** |
25.2 |
11.0 |
82.1 |
|
On-site Internist Rheumatologist |
4.7 |
6.9 |
0 |
|
Off-site Internist Rheumatologist |
1.6 |
1.4 |
3.6 |
|
General Pediatrician |
2.4 |
2.7 |
0 |
|
Other |
5.5 |
5.5 |
10.7 |
|
None |
18.9 |
0.0 |
0.0 |
|
a Programs could choose more
than one provider.
* Difference between program types significant
at p<0.05
** Difference between program types significant
at p<0.01
*** Difference between program types significant
at p<0.001
Programs that lack pediatric rheumatology
rotations were significantly more likely
to report having a greater percentage
of graduates in primary care positions
(Table 18). Directors from 64 percent
of programs with on-site rheumatology
training estimated that one-half of their
graduates practiced in primary care.
In contrast, over 90 percent of directors
in programs without a pediatric rheumatology
rotation available estimated that over
half of their graduates practiced in primary
care.
Despite the availability of formal pediatric
rheumatology rotations in 79 percent of
pediatric residency programs, few pediatric
residents elect to take these rotations;
only three of these programs (2.4 percent)
require a pediatric rheumatology rotation.
In addition, only 11.9 percent of program
directors estimate that more than 50 percent
of their residents do a formal pediatric
rheumatology rotation. Compared to programs
with away electives programs, on-site
rotations report having a significantly
higher percentage of residents doing a
rheumatology rotation. In programs with
on-site training, one-half of directors
estimate that more than one-quarter of
their residents do a pediatric rheumatology
rotation during their training. Among
those programs with an away elective,
all directors estimate that 25 percent
or less of their residents elect to take
this rotation.
Directors were asked to indicate which
faculty were involved in four curriculum
components relevant to rheumatology:
joint exam, rheumatology laboratory evaluation,
JRA diagnosis and JRA treatment. Directors
could choose from one or more of the following:
pediatric rheumatologist, internist rheumatologist,
general pediatrician/continuity clinic,
and lectures/guest speaker. Programs
were classified into one of nine mutually
exclusive categories. Programs were characterized
by the involvement of a pediatric rheumatologist
either alone or in combination with other
providers; programs that did not report
using pediatric rheumatologists in a curriculum
component, were then assessed for their
use of internist rheumatologists and others.
Pediatric rheumatology curriculum components
were taught largely by pediatric rheumatologists
independently or in combination with other
faculty or guest speakers (Table 19).
A small percentage of programs relied
upon internist rheumatologists with or
without the involvement of general pediatricians
and/or guest lectures to cover these components;
a small number of programs relied on general
pediatricians. With the exception of
the joint exam component, at least two-thirds
of directors indicated that a pediatric
rheumatologist was involved in the curriculum
components studied.
Table
19: Faculty Involvement in Pediatric
Rheumatology Curriculum, 2004 Survey of
Program Directors (n=126)
17.3 |
21.3 |
23.6 |
33.1 |
47.2 |
47.2 |
44.9 |
37.8 |
0.8 |
3.2 |
2.4 |
3.9 |
7.9 |
11.0 |
11.0 |
11.0 |
12.6 |
9.5 |
11.0 |
6.3 |
10.2 |
3.9 |
2.4 |
3.2 |
1.6 |
0.8 |
1.6 |
1.6 |
0.8 |
0.8 |
1.6 |
1.6 |
1.6 |
2.4 |
1.6 |
1.6 |
a “Other” includes internist
rheumatologist and/or general pediatrician
and/or lectures/guest speakers and/or
other rheumatologist.
b “Other” includes general
pediatrician and/or lectures/guest speakers
and/or other rheumatologist.
When one examines faculty involvement
in the pediatric curriculum components
by availability of a staff pediatric rheumatologist,
the importance of having a pediatric rheumatologist
on staff becomes more readily apparent.
Faculty involvement was collapsed into
three mutually exclusive categories:
pediatric rheumatologist involved, internist
rheumatologist involved without a pediatric
rheumatologist, and general pediatrician
or other provider. These classifications
were compared between programs with and
without staff pediatric rheumatologists
for each of the four curriculum components.
Programs without pediatric rheumatologists
at their institutions were significantly
more likely to rely on internist rheumatologists
and/or general pediatricians to address
these curriculum areas (Table 20). For
each curriculum component, nearly 100
percent of the programs with a pediatric
rheumatologist on staff at their affiliated
institution report their involvement in
these training areas. In contrast, more
than two-thirds of programs without pediatric
rheumatologists at their affiliated institutions
report that training in these areas was
the domain of internist rheumatologists,
general pediatricians, continuity clinics,
and lectures and/or non-rheumatologists.
It is interesting to note that approximately
one-third of the programs without pediatric
rheumatologists on staff nonetheless were
able to involve them in their resident
training.
Table
20: Faculty Involvement in Pediatric
Rheumatology Curriculum Components by
Availability of a Staff Pediatric Rheumatologist
on Site, Pediatric Residency Director
Survey (n=126)***
Pediatric
rheumatologist only or in combination
with other providers, continuity
clinic and/or lectures |
24.5 |
95.8 |
30.8 |
98.6 |
32.1 |
97.2 |
35.9 |
98.6 |
Internist
rheumatologist only or in combination
with other providers,a
continuity clinic and/or lectures |
20.8 |
0.0 |
32.7 |
1.4 |
30.2 |
1.4 |
34.0 |
1.4 |
General
pediatricians or continuity clinic
with lectures and/or other non-rheumatologist |
54.7 |
4.2 |
36.5 |
0.0 |
37.7 |
1.4 |
30.2 |
0.0 |
a Except pediatric rheumatologists
*** For each curriculum component and
faculty classification, the difference
between programs with and without staff
pediatric rheumatologists are significant
at p<0.001.
Availability
of Pediatric Rheumatology Training in
Medical Schools
Dr. Charles Spencer, president of the
AAP Section of Pediatric Rheumatology
and Professor of Pediatrics at the University
of Chicago and La Rabida Children’s Hospital
and Research Center, received a three-year
award from the American College of Rheumatology
to assess the status of pediatric rheumatology
education in medical schools. Dr. Spencer
found that of 53 responding clerkship
directors (50 percent), one-quarter lacked
a pediatric rheumatologist at their institutions
on at least a part-time basis. Over 20
percent relied on a non-pediatric rheumatologist
to teach pediatric rheumatology. More
than three-quarters reported that a pediatric
rheumatologist does not lecture to medical
students during their pediatrics clerkship.
Only one-half of programs offer a pediatric
rheumatology rotation to medical students.
Thus, exposure to pediatric residency
in medical school is quite low. 34
Pediatric Rheumatology
Visiting Professorship Programs
One approach to expanding exposure to
pediatric rheumatology training within
pediatric residency is Pediatric Rheumatology
Visiting Professorship Programs. Through
these programs pediatric rheumatologist
visiting professor programs are offered
to schools that lack a pediatric rheumatology
program. 35
However, funding of such programs are
limited. Thus, it has only a limited
ability to address the needs of the many
institutions without pediatric rheumatologists
on staff.
Issue 2:
Insufficient Clinical Care Cost Recovery/
Financing Pediatric Rheumatology Positions
Initial and follow-up patient visits
in pediatric rheumatology are quite lengthy
and involved. However, they do not usually
include separate billable procedures that
generate additional funds. Many other
specialists often perform procedures that
increase revenue. The revenue from pediatric
rheumatologist extended office visits
is insufficient to cover costs.
Adequacy of
Reimbursement
Medicaid provides health insurance for
approximately 12 percent of the under
18 population in the United States. In
contrast, pediatric rheumatologists estimate
that one-third of their patients are covered
by Medicaid. 22
As such, Medicaid reimbursement is particularly
relevant to the financial viability of
pediatric rheumatology practices.
Although past studies have shown that
Medicaid and State Children’s Health Insurance
Programs (SCHIP) improves access for children
who would otherwise be uninsured, Medicaid
enrollees are significantly less likely
than children with private coverage to
receive a referral to specialty care,
to receive specialty care, or to receive
that care from a Board-certified physician.
7,
36-39
This pattern is similar to previous research,
which, while not specific to specialty
care, has shown that children with Medicaid
have greater unmet needs than children
with private insurance and fewer unmet
needs than uninsured children. 9,
40-42
Some studies have suggested that the
discrepancy in access observed between
Medicaid-insured children and their privately
insured counterparts is due, in part,
to inadequate provider reimbursement.
The existing literature leaves no doubt
that the adequacy of reimbursement, especially
from public insurers, is insufficient
to ensure access to pediatric subspecialty
care. A study of access to surgical care
for children with government-sponsored
insurance found that only 27 percent of
surgeons were willing to provide care
to children with Medi-Cal vs. 97 percent
being willing to treat privately insured
children. Excessive administrative burden
and low monetary reimbursement from the
procedure were cited by 96 percent and
92 percent of respondents. One study
in California found that children insured
by Medi-Cal experienced significantly
greater delays in treatment for fracture
than privately insured peers; the authors
of this study showed the Medi-Cal reimbursement
for a follow-up visit for a broken arm
was less than one-half that of Medicare.
43
A study of access to care for enrollees
in SCHIP in five States found that that
low reimbursement rates dissuaded pediatric
subspecialists from participating in the
program and contributed to hospitals’
inability to retain pediatric subspecialists.
44
Low levels of reimbursement may not be
limited to Medicaid-insured patients,
however. A study of developmental-behavioral
pediatricians found that inadequate reimbursement
was the most commonly reported constraint
to seeing more patients. 45
Likewise, a survey of State Title V directors
found that 44 percent cited inadequate
reimbursement as a significant access
barrier to pediatric subspecialty care
receipt among children with health care
needs. 46
These directors cited increased reimbursement
rates as essential to improving the availability
of and access to medical homes for children
with special needs.
Reimbursement
& Recruiting Pediatric Rheumatologists
In the survey of pediatric residency
directors, respondents were asked, to
the best of their knowledge, if efforts
had been made to recruit one or more pediatric
rheumatologists to their institutions
in the previous 5 years. Nearly one-quarter
had successfully recruited one or more
pediatric rheumatologists and an additional
11.2 percent had been unsuccessful in
their recruitment efforts. Over one-third
of programs reported an interest in recruiting
a pediatric rheumatologist but an inability
to recruit for financial or other reasons.
Only 13 percent of the programs felt they
did not need such a provider and 16 percent
did not know about their institution’s
interest in hiring a pediatric rheumatologist.
Open-ended comments from these residency
directors suggest that financial factors
heavily influence their programs ability
to hire a pediatric rheumatologist:
- “… It should be noted that our
rheumatologist functions as a generalist
and teacher both in the clinic, newborn
nursery and on the pediatric floor.
He spends the majority of his time in
these endeavors, not in rheumatology
… We would not be able to support a
full-time rheumatologist and consider
ourselves fortunate to have one who
is also such a wonderful generalist
and teacher.”
- “The major barriers to bringing
pediatric rheumatology to our center
are lack of available ped[iatric] rheumatologists
to recruit, funding based on clinically
generated dollars (although our referral
base is at the level to theoretically
support the position), convincing [institution
name] re: the financial viability of
the position, finding ancillary dollars
(education, research, etc) in a community-based
academic residency, providing cross-coverage
for on-call, etc.”
- “We probably do not have sufficient
patients within our tri-county referral
area to justify a full-time on-site
Peds Rheumatologist, nor do we have
anything close to the budget for same
…”
- “To get an on-site specialist we
would have to show that it is "cost-effective"
to hire them, and with our population
this would not be the case.”
Issue 3:
Research Requirements Limit Patient Access
to Care
Pediatric rheumatologists generally
divide their professional time across
three activities: patient care, research,
and medical education. Past research
shows that having an interest in research
and medical education is positively associated
with pursuit of subspecialty training
among pediatricians. 9,
47,
48
In other words, pediatric trainees with
an interest in research are significantly
more likely than those with lower levels
of interest in research to pursue subspecialty
training. Therefore, efforts to increase
the supply of pediatric rheumatologists
may be improved by acknowledging the importance
of research opportunities as an incentive
to subspecialization.
Data from the AF/ACR survey reveal that
the majority of pediatric rheumatologists
spend less than 20 percent of their time
in research while a small percentage of
these providers spend the majority of
their time in research activities; suggesting
that most pediatric rheumatologists specialize
in either research or patient care (Figure
6). The level of research involvement
among pediatric rheumatologists was significantly
greater than internist rheumatologists,
highlighting the relative importance of
competing professional demands for pediatric
rheumatology.
Figure
6: Percent of Professional Effort Spent
on Research by Specialty
[D]
Source: AF/ACF Survey, 2004
There has been no investigation to date
of the extent to which the current supply
of pediatric rheumatologists affects their
involvement in research; however, one-sixth
of pediatric rheumatologists responding
to the AF/ACR survey had decreased their
patient care time in the previous 5 years
because they obtained salary from a research
source. As a result, successful receipt
of research funding limits the amount
of time that these providers are available
for patient care.
In addition to personal interest in research,
the transition to increased reliance on
research-based funding may be due, in
part, to incentives inherent in academic
medical practice. As a cognitive, or
non-procedural, pediatric subspecialty,
pediatric rheumatology tends to generate
low levels of clinical revenue because
it involves mainly outpatient evaluation
and management. Due to low levels of
clinical revenue, academic medical centers
often find it difficult to underwrite
the costs of cognitive pediatric subspecialty
practices. For this reason as well as
the general mission of academic medical
centers to foster research, many pediatric
rheumatologists experience pressure to
obtain research funding. Many research
funding sources, such as those discussed
in the following sections, require that
providers devote a certain percentage
of time to research endeavors, thereby
forcing a decrease in their involvement
in patient care.
Pediatric Rheumatology
Research Funding
Using data from the National Institutes
of Health’s (NIH) CRISP database, all
NIH grants awarded to individuals with
“pediatrics” or “rheumatology” in the
position title between 1999 and 2003 were
identified. Data from the CRISP database
were merged with pediatric rheumatologists’
data from the ACR using the first and
last names of the principal investigator.
Of 361 unique grants, only 7 were awarded
to pediatric rheumatologists listed in
the ACR file and all 7 went to the same
two doctors. This suggests that few pediatric
rheumatologists are successfully competing
for NIH funding, but the completeness
of the CRISP data for pediatric rheumatologists
is not known.
While many NIH grants, such as Small
Grant Awards (R03) and Investigator Initiated
Grants (R01) do not specify the amount
of time that a physician must be involved
in the grant, Research Career Awards generally
require that the recipient spend 75 percent
of their professional effort in research
endeavors. Consequently, pediatric rheumatologists
receiving these grants spend 25 percent
or less of their time in patient care.
Additional
Funding Sources
Concerns about fellowship and research
funding have led to the development of
specific programs that fund either fellowship
training or junior researchers. The American
College of Rheumatology, for example,
has a Clinical Investigator Fellowship
Award that provides training in clinical
investigation to rheumatology fellows
or rheumatologists early in their careers.
49
Similarly, the ACR and the Arthritis Foundation
specifically provide awards for fellows
during training and for young investigators.
Some of these awards target pediatric
rheumatologists while others fund both
internist and pediatric rheumatologists.
The awards provide salary support to physicians
in fields where clinical revenues are
often insufficient to fund positions;
however, they may lead to reductions in
the amount of time a provider spends in
patient care.
The NIH sponsors a Pediatric Research
Loan Repayment Program (Pediatric Research
LRP) directed to physician and non-physician
researchers active in pediatrics. In
exchange for a 2-year commitment to pediatric
research, the NIH will pay up to $35,000
of educational expenses, an additional
39 percent to cover federal taxes, and
reimburse awardees for State taxes due
on the payments. In 2003 almost 500 people
applied for the Pediatric Research LRP;
nearly 300 received awards. This program
requires, however, that recipients spend
50 percent of their time in research endeavors,
again limiting their availability for
patient care.
While programs like the Pediatric Research
LRP are not specifically targeted to pediatric
rheumatology, they provide pediatric rheumatology
fellows and young investigators with opportunities
to discharge some of the financial burdens
of undergraduate and graduate medical
education. Along with targeted programs
like those available through the American
College of Rheumatology and the Arthritis
Foundation, these efforts attempt to address
some of the potential causes of pediatric
rheumatology shortages. While these programs
do provide funding for pediatric rheumatologists’
salaries, research requirements detract
from their availability for full-time
patient care and create a tradeoff between
the availability of patient care and the
scientific advancement of the field through
research.
Pediatric rheumatologists largely function
as patient care providers, educators,
and researchers. Supply constraints limiting
their available research time may delay
much-needed advances in the cure of pediatric
rheumatic diseases. The more time a provider
devotes to research, the less time they
have available for patient care. The
conundrum is that research is at the expense
of clinical care or vice versa.
Summary
Over one-third of medical schools and
over 40 percent of pediatric residency
programs lack a pediatric rheumatologist
on staff, decreasing exposure to this
field. As a consequence, medical students
and pediatric residents may lack sufficient
experience with pediatric rheumatology
to develop an interest in the field or
to feel comfortable co-managing the care
of children with rheumatic diseases.
As such, decreased availability of pediatric
rheumatologists in training sites may
perpetuate shortages and decrease the
availability of substitutes for pediatric
rheumatology care. This vicious cycle
increases demand for pediatric rheumatologists
by increasing the number of children referred
for evaluation of conditions, such as
fever of unknown origin and joint complaints
that could sometimes be addressed by adequately
trained primary care providers.
A unique feature of pediatric subspecialties,
like pediatric rheumatology, is that the
same pool of providers sees patients,
performs research, and educates physicians-in-training.
Several studies suggest that research
opportunities are a major motivation to
subspecialize among pediatricians; therefore,
many pediatric rheumatologists likely
entered the field in order to do research
as well as patient care. Furthermore,
academic medical centers are the dominant
employer of pediatric rheumatologists
and the demands of academic practice dictate
much of their professional behavior.
Non-procedural or cognitive pediatric
subspecialties often fail to generate
sufficient clinical revenue due to low
reimbursement rates for non-procedural
visits. As such, academic medical centers
often rely on research revenue to fund
pediatric subspecialty positions. Without
these research dollars, fewer academic
medical centers may be able to afford
pediatric rheumatologists. The survey
of pediatric residency directors found
that one-third of programs would like
to hire a pediatric rheumatologist but
were unable to do so for financial or
other reasons. Thus, involvement in non-patient
care activities, such as research, may
be essential to financing positions for
pediatric rheumatologists while negatively
affecting the amount of time a provider
has available for patient care.
|