Who Will Treat Arthritis in 2005?

This article is part one of a four-part series on the 2006 Rheumatology Workforce Study.

Results of the first rheumatology workforce study in the past 10 years were released last November, confirming concerns that the supply of rheumatologists may not meet demand in the near future. The extensive report, commissioned by the ACR, lays out the hard facts about this medical specialty that its practitioners had long anticipated were true—the number of practicing rheumatologists does not meet the current or future needs of the patient population, patients are waiting longer for appointments, and practices must be redesigned to preserve and improve the quality of the profession.

In a response to the 2006 Rheumatology Workforce Study, President Neal S. Birnbaum, MD, told attendees at the ACR Annual Meeting in Washington, D.C., last November that the workforce report—and the professional specialty—are a study in contrast. “Never has there been such a rich period of opportunity for rheumatologists to improve the lives of their patients,” says Dr. Birnbaum. “Yet the American College of Rheumatology knows that our members confront significant challenges in a rapidly changing environment: declining reimbursements, increasing paperwork, and complex, confusing, and at times inexplicable demands from insurance companies and government.” In addition, Dr. Birnbaum says, “Practitioners face increasing demand for services at a time when our aging rheumatology workforce might typically intend to reduce its workload.”

Supply and Demand Snapshot

Dr. Birnbaum’s remarks echo the findings in the workforce study. The genesis of the study was an advisory group formed by the chairman of the ACR Committee on Training and Workforce Issues, Walter Barr, MD, and led by Chad Deal, MD. ACR members informally had discussed perceptions of a shortage among rheumatologists and knowledge of longer wait times for patients as well as difficulty in recruiting practice partners. The study, says Dr. Barr, allowed the ACR to validate and reinforce these general impressions and outline potential solutions and formal goals. The advisory group first met in early 2005 and immediately sought the expertise of The Lewin Group, a Falls Church, Va., consulting firm that specializes in strategic and analytical services in healthcare and human services.

The purpose of the study was to better understand the factors affecting the supply of and demand for rheumatologists, to quantify factors where possible, to project likely paths for the evolution of the workforce, and to assess its implications. As part of the study, The Lewin Group conducted a survey of practicing rheumatologists between November 2005 and February 2006. The analysis also included a literature review and guidance and input from advisory group members.

• The study results cover the following areas:
• Demographics of current rheumatologists;
• Current practice patterns and trends;
• Prevalence of diseases requiring the expertise of a rheumatologist;
• Technological advances that have affected the need for this specialty profession;
• Changes in practice efficiency;
• Supply and demand;
• Retirement trends;
• Adult versus pediatric rheumatologists;
• Earnings and job satisfaction; and
• Distribution of work hours.

The workforce study projects that the number of rheumatologists in adult practice will increase only 1.2% between 2005 and 2025. However, the demand for rheumatologists to treat patients in that time period will rise 46%. Analysts say the increase in demand will come from several factors: an overall increase in the population, an increase in the number of elderly patients, and a general rise in per capita income.

What can the profession do to meet this demand? The workforce study recommends increasing fellowship positions, increasing the work effort of rheumatologists, improving practice efficiency, and using more allied health professionals including trained rheumatology nurse practitioners and physician’s assistants. Two professionals who played a significant role in identifying these possible solutions are Tim Harrington, MD, a rheumatologist in practice at the University of Wisconsin who has studied and developed alternative practice designs, and Rod Hooker, PhD, PA, a physician assistant in a rheumatology practice at the University of Texas Southwest in Dallas.

Literature Overview

The backdrop for the study results is a review of the literature on the prevalence and costs of musculoskeletal diseases, technological advances in the treatment of RA and lupus, practice efficiency, and changes in Medicare coverage and payment policies.

The review found that arthritis and musculoskeletal disorders are among the most frequently occurring chronic conditions in the U.S. Approximately 47.8 million Americans had arthritis in 2005. That number is expected to rise to 67 million in 2030. Another 2.1 million Americans had rheumatoid arthritis in 2005; juvenile rheumatoid arthritis cases in the U.S. number between 30,000 and 50,000, with half of the cases being inactive. The prevalence of RA is estimated to rise to 2.8 million by 2025. Osteoarthritis is the most common type of arthritis. Estimates are that 20.7 million Americans had osteoarthritis in 2005 and that the prevalence will rise to 28.1 million by 2025. Studies show that women are nearly eight times more likely to have osteoarthritis than men.

Medicare and other payment policies have changed in the past few years in ways that affect the demand for rheumatology services. The Medicare Replacement Drug Demonstration allowed a limited number of beneficiaries with rheumatoid or psoriatic arthritis to receive coverage for self-injecting biologics. Medicare Part D now covers this therapy. Reimbursement for on-site infusion has been decreased, which may require rheumatologists to reduce the number of infusion sites and the size of staff to cover costs.

Current and Future Workforce

Researchers used AMA files supplemented with the ACR membership list to identify 4,946 current adult rheumatologists and 218 pediatric rheumatologists in the U.S. The vast majority (94% adult rheumatologists and 92% pediatric rheumatologists) treat patients. The median age for adult specialists is 51; for pediatric rheumatologists, it’s 47. Approximately 70% of adult rheumatologists are male; 51% of pediatric rheumatologists are female.

The number and geographic location of rheumatology practices in the United States varies significantly. Boston has both the highest number of adult and pediatric rheumatologists. Areas with the highest concentration are in large urban areas such as metropolitan New York/New Jersey and metropolitan Los Angeles. But the distribution patterns are not consistent in all large cities; Dallas-Ft. Worth and Houston have much lower numbers. Phoenix, Ariz., (population 3.5 million) has no pediatric rheumatologists. The areas with the lowest concentration of adult rheumatologists include major population areas such as Baton Rouge, La., and Bakersfield, Calif.

Some much less populated areas that have an academic or specialty medical center such as Rochester, Minn. (Mayo Clinic), and Marshfield, Wis. (Marshfield Clinic), have a high concentration of adult rheumatologists. The need for pediatric rheumatologists is striking in many metropolitan areas, even those with a population of more than one million, including Las Vegas, Nev.; San Antonio, Texas; Charlotte, N.C.; Austin, Texas; and Birmingham, Ala. Areas with the highest concentration of adult rheumatologists are New England and the Mid-Atlantic. The central and mountain states, Hawaii, and Alaska, have the lowest concentration.

A secondary factor that affects the future workforce is the number of rheumatologists who plan to retire in the near future. This number may be offset by the number of medical school graduates who will fill a rheumatology fellowship. The study predicts that the number of fellowship positions is not likely to increase but will remain constant, as will the number of international medical school graduates. There is also likely to be an increase in the demand for both adult and pediatric rheumatologists, based on increases in the U.S. population as a whole and an increase in real personal income per capita.

Dr. Birnbaum says in his response to the study that it is highly unlikely that the number of fellowships in rheumatology can be increased to meet the growing demand. “The expansion of current training capacity in rheumatology would require not only an increase in salary support for fellows,” he says, “but also meaningful growth in training resources including academic faculty, dedicated space for educational endeavors, and increased clinical opportunities.” He continued, “It seems unlikely that we will see any significant growth in the number of rheumatologists entering the workforce any time soon.”

Practice Patterns

Most practicing rheumatologists are white (79%) and married (89%). Nearly half (44%) of women in practice have school-aged children. The primary practice setting is split among group practice (43%), solo or partnership practice (32%), and medical school (16%). Nearly three-quarters (74%) have an infusion unit, 64% densitometry, 55% X-ray, and 61% an on-site laboratory. A growing number (21%) of practices have early arthritis centers. The survey found that the majority of pediatric rheumatologists were unwilling to treat a patient over age 18 (44.9%) or age 21 (33.3%). Among adult rheumatologists, 27.7% says the youngest they would want to treat a patient would be 16 to 17 years, and another 22.4% says they would be reluctant to treat a patient age 12 to 15.

Most practicing rheumatologists are white (79%) and married (89%). Nearly half (44%) of women in practice have school-aged children. The primary practice setting is split among group practice (43%), solo or partnership practice (32%), and medical school (16%). Nearly three-quarters (74%) have an infusion unit, 64% densitometry, 55% X-ray, and 61% an on-site laboratory. A growing number (21%) of practices have early arthritis centers.

The survey found that the majority of pediatric rheumatologists were unwilling to treat a patient over age 18 (44.9%) or age 21 (33.3%). Among adult rheumatologists, 27.7% says the youngest they would want to treat a patient would be 16 to 17 years, and another 22.4% says they would be reluctant to treat a patient age 12 to 15.

Only a small percentage of practices currently employ a nurse practitioner (15.5%) or a physician’s assistant (7.2%). This finding is important since the study recommends adding these professionals to a practice as a key way to address workforce shortages.

Family status was shown to have a dramatic impact on the number of hours worked by female versus male rheumatologists. The overwhelming majority (83%) of female rheumatologists are married and of that number 26% have preschool-aged children. Married women rheumatologists report working 440 fewer hours per year and women with children under six work 660 hours less per year than their single counterparts. In contrast, married men who are rheumatologists work 330 more hours a year than single men but those with children under age 18 work 100 less hours annually.

Male and female adult and pediatric rheumatologists are all pretty satisfied with their work. Only 6% to 10% reported any level of dissatisfaction. However, the need for more colleagues in a practice is evident. More than 30% are in practices that are currently looking to hire another rheumatologist and more than half are in practices that plan to hire additional partners within the next five years. Income levels reported in the survey show that the median income for a rheumatologist is between $151,000 and $193,000. More than half (57%) of full-time rheumatologists receive an income between $100,000 and $250,000.

Walter Barr, MD

The workforce study also points to reported wait times for patients as a strong indication of excess demand. The mean wait time for a non-urgent patient is 37 days and almost half of the rheumatologists surveyed said that their non-urgent patients waited more than four weeks for an appointment. The wait time for new rheumatology patients is higher than for general medicine and other specialty referrals such as cardiology and gastroenterology. These data point to the need for practice redesign, an area of concern that the ACR is already beginning to address.

Chad Deal, MD

The ACR is confident that the 2006 Rheumatology Workforce Study will meet the needs of the profession into the future. It includes a computer modeling tool that allows for periodic reassessment of the projections made in the study. “Perhaps the real value to any workforce study is that it forces us to evaluate our profession,” says Dr. Birnbaum. “The study challenges us to consider the impact on the practice of our members and how to prepare our members to continue