preparingforlobbyday - american college of nurse-midwives ·...
TRANSCRIPT
Preparing for Lobby Day
ACNM’s 2015 Annual Mee1ng Jesse S. Bushman
Director, Advocacy and Government Affairs American College of Nurse-‐Midwives
The Three Handouts 1. Essen1al Facts about Midwives 2. The Improving Access to Maternity Care Act
of 2015 (H.R. 1209/S. 628) 3. Midwifery and Addressing the Shortage of
Maternal Care Providers
Pa7ent Needs
Projected Numbers of Women, 2014-‐2035
50,000,000
70,000,000
90,000,000
110,000,000
130,000,000
150,000,000
170,000,000 2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
Age 15+
Age 15-‐49
Source: US Census Bureau: hZps://www.census.gov/popula1on/projec1ons/data/na1onal/2014/downloadablefiles.html
Nearly 24 million more women (7 million of childbearing age) will need care in 2035.
Projected Births in the United States – 2014-‐2035
3,000,000
3,200,000
3,400,000
3,600,000
3,800,000
4,000,000
4,200,000
4,400,000
4,600,000
4,800,000
5,000,000 2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
Source: US Census Bureau: hZps://www.census.gov/popula1on/projec1ons/data/na1onal/2014/downloadablefiles.html
The Census Bureau es7mates a 6.3% increase in the number of births per year by the end of this 7meframe.
Pregnancy and Newborn Care Hospital Discharges Together Far Outnumber Discharges for any Other Major Diagnos7c Category
Source: http://hcupnet.ahrq.gov/HCUPnet.jsp Last accessed 4/7/15. Data reflect discharges in 2012.
0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000
Infec7ous & Parasi7c Diseases
Mental
Kidney & Urinary Tract
Nervous System
Diges7ve System
Musculoskeletal System & Conn Tissue
Respiratory System
Newborns & Other Neonates
Pregnancy, Childbirth
Circulatory System
1,428,045
1,428,060
1,671,380
2,192,941
3,242,725
3,251,134
3,549,166
3,933,511
4,160,286
4,796,175
Number of Discharges
Workforce Demographics
Maternal Care Providers per 10,000 Women Age 15-‐49 Years
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00 2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Providers p
er 10,00
0 Wom
en
OB/GYNs CNMs/CMs Total
“Maternal Care Providers” includes OB/GYNs (Fellows and Jr. Fellows), and CNMs/CMs. Source: ACOG, AMCB and 2014 Na1onal Popula1on Projec1ons, US Census Bureau, available at: hZps://www.census.gov/popula1on/projec1ons/files/summary/NP2014-‐T3.xls
• Many providers are not clinically ac7ve. • As the popula7on ages, a larger por7on of clinician 7me will
be taken up rendering primary care to older women.
Maternal Care Providers per 10,000 Women Age 15+ Years
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00 2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Providers p
er 10,00
0 Wom
en
OB/GYNs CNMs/CMs Total
“Maternal Care Providers” includes OB/GYNs (Fellows and Jr. Fellows), and CNMs/CMs. Source: ACOG, AMCB and 2014 Na1onal Popula1on Projec1ons, US Census Bureau, available at: hZps://www.census.gov/popula1on/projec1ons/files/summary/NP2014-‐T3.xls
The ra7o has not changed appreciably in 16 years.
First-‐Year OB/GYN Residents and Newly Cer7fied CNMs/CMs, 1979 -‐ 2014
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
1979 1987 1993 1998 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
1st Year OB/GYN Residents Newly Cer7fied CNMs/CMs
Source: William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implica1ons, American Congress of Obstetricians and Gynecologists, 2011, Tables 1-‐4 and 2-‐1. Accredita1on Council for Graduate Medical Educa1on, Years 2011-‐2014. See: hZp://www.acgme.org/acgmeweb/tabid/259/GraduateMedicalEduca1on/GraduateMedicalEduca1onDataResourceBook.aspx American Midwifery Cer1fica1on Board – See: hZp://www.amcbmidwife.org/docs/default-‐document-‐library/cer1ficants-‐1971-‐-‐-‐present.pdf?sfvrsn=4
• The number of medical graduates entering OB/GYN residencies has remained rela7vely flat for three decades.
• New CNMs/CMs have been increasing recently.
Distribu7on of OB/GYNs by Age
0% 5%
10% 15% 20% 25% 30% 35% 40% 45% 50%
<35 Yrs 35-‐44 Yrs 45-‐54 Yrs 55-‐64 Yrs 65+ Yrs
5.20%
16.60%
26.90%
31.20%
20.10%
24.70%
29.80%
25.30%
11.80%
3.40%
Age
Males Females
Source: William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implica1ons, American Congress of Obstetricians and Gynecologists, 2011. * 2014 Physician Specialty Data Book, AAMC Center for Workforce Studies, November 2014.
• More than 15,000 OB/GYNs will likely re7re in the next decade, outpacing the rate of new OB/GYNs entering the profession by 20%. Most of the re7ring OB/GYNs will be male.
• In 2013, 82.6% of first year OB/GYN residents and interns were women.
• Over 7me, the OB/GYN profession will become predominantly female.
Mul7ple Studies Show Female Physicians Work Fewer Hours than Male Physicians
A 2006 AAMC survey found that among physicians who had the op7on to work part 7me, 34% of female physicians did so, while only 7% of male physicians did.
Age
Average Ho
urs W
orked pe
r Week, 2005-‐2007
Source: 2009 AAMC Annual Mee1ng Presenta1on, available at: hZps://www.aamc.org/download/82844/data/annualaddress09.pdf AAMC Press release, available at: hZps://www.aamc.org/newsroom/reporter/sept2011/260020/part-‐1me.html
Average Age at which ACOG Fellows Stop Prac7cing Obstetrics
25
30
35
40
45
50
55
1992 1996 1999 2003 2006 2009
50.2
48.4 51
.2
51
51.7
51.9
39.5
39.2 40.8 42
43.1
43.8
Age (years)
Year of Study
Males
Females
Source: William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implica1ons, American Congress of Obstetricians and Gynecologists, 2011.
Bofom Line: Serious Workforce Challenges
Sta7c Entries into OB/GYN Specialty
Changes in Provider Demographics
Increasing Pa7ent Needs
Serious Workforce Challenges
ACOG has projected a shortage of between 15,723 – 21,723 OB/GYNs by 2050.
Source: William F. Rayburn, MD, MBA, FACOG, “The Obstetrician Gynecologist Workforce in the United States: Facts, Figures, and Implica1ons, American Congress of Obstetricians and Gynecologists, 2011.
Workforce Maldistribu7on Compounding the Problem
Obstetrician/Gynecologists per 100,000 Popula7on Data Current as of 2011
Out of 3,142 U.S. Coun7es, 1,459 (46%) have no OB/GYN. Source: Area Resource File. Slide originally created on 3/1/2014 by Kate Crawford, Birth by the Numbers (www.birthbythenumbers.org) See also: “The Obstetrician Gynecologist Workforce in the United States, Facts, Figures, and Implica1ons,” American Congress of Obstetricians and Gynecologists, 2011
0
0.1 – 29.9
30.0 +
OB/GYNs per 100,000
ACOG es7mates that in 2011, there were 9.5 million people living in a county without a single OB/GYN.
Cer7fied Nurse-‐Midwives per 100,000 Popula7on Data Current as of 2011
Out of 3,142 U.S. Coun7es, 1,758 (56%) have no CNM.
Source: Area Resource File. Slide originally created on 3/1/2014 by Kate Crawford, Birth by the Numbers (www.birthbythenumbers.org)
0
0.1 – 4.9
5.0 +
CNMs per 100,000
CNMs and OB/GYNs per 100,000 Popula7on Data Current as of 2011
Out of 3,142 U.S. Coun7es, 1,263 (40%) have no CNM or OB.
0
0.1 – 29.9
30.0 +
CNMs & OB/GYNs per 100,000
Source: Area Resource File. Slide originally created on 3/1/2014 by Kate Crawford, Birth by the Numbers (www.birthbythenumbers.org)
Geing More Data: H.R. 1209/S. 628 “Improving Access to Maternity Care Act of 2015”
• HRSA to designate maternity care health professional shortage areas – loca1ons or popula1ons without sufficient full scope maternity care providers or hospitals or birth center labor and delivery units.
• NHSC scholarships and loans could be available to maternity care providers who agree to work in these new shortage areas.
Pa7ent Popula7on and
Workforce Structure
Pregnancy and Risk Stra7fica7on
Higher Risk
Pregnancies
Normal Pregnancies
There is no uniformly u1lized defini1on of a high risk pregnancy.
• CDC es1mates that in 2013, 83% of first 1me mothers were at low risk for a cesarean birth.1
• The NIH lists several high risk factors affec1ng 2-‐10% of pregnancies.2
1 Percentage derived from number of low risk women, shown in Table I of the technical notes here: hZp://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_06.pdf and from the total number of first 1me mothers, derived from hZp://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm 2 See: hZp://www.nichd.nih.gov/health/topics/high-‐risk/condi1oninfo/Pages/risk.aspx
It is reasonable to assume that the majority of women are able to have a normal pregnancy and delivery.
OB/GYN and CNMs/CM Capabili7es Overlap Both are Necessary
OB/ GYNs
CNMs/ CMs
An Increasing Percent of OB/GYNs are Subspecializing
Obstetrics/Gynecology
Maternal-‐Fetal
Medicine
Reproduc7ve Endocrinology and Infer7lity
Gynecologic Oncology
Female Pelvic Medicine and Reconstruc7ve
Surgery
Pediatric and
Adolescent Gynecology
Minimally Invasive
Gynecologic Surgery and Pelvic Pain
Menopausal and Geriatric Gynecology
Growing the midwifery workforce will allow women experiencing normal birth to do so with a skilled afendant, while also permiing physicians to dedicate the necessary 7me to subspecializa7on so that these unique skills will be available to pa7ents with atypical needs.
Many Other Countries Make Much More Extensive use of Midwives
0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00
19.49
15.67
9.67
6.54
4.52
4.39
3.94
3.83
3.23
2.57
2.54
1.94
1.57
1.21
1.06
1.00
0.87
0.83
0.40
0.28
Midwives Per Obstetrician in 20 Developed Countries
Sources listed in Notes View.
Greater use of midwifery in the US should be a significant aspect of addressing the shortage of in skilled maternal care providers.
Educa7ng and Preparing Midwives is Compara7vely Swin and Economical
0
1
2
2 Years
Length of Typical Midwifery Educa7on Program
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
2015
$53,505
Average Cost of Midwifery Educa7on
Midwifery educa1on costs from Kathleen Fagerlund, CRNA, PhD, and Elaine Germano, CNM, DrPH, “The Costs and Benefits of Nurse-‐Midwifery Educa1on: Model and Applica1on,” Journal of Midwifery and Women’s Health, Vol. 54, No. 5, September/October 2009, pp. 341-‐350. This ar1cle reports 2008 dollars for tui1on, fees, books and supplies which were inflated to 2015 dollars using an infla1onary rate of 2.8% per year, per the infla1onary rate for public college tui1on/fees from the College Board, available at: hZp://trends.collegeboard.org/college-‐pricing/figures-‐tables/average-‐rates-‐growth-‐published-‐charges-‐decade
• 13 of the 39 midwifery educa7on programs offer a 3-‐year DNP program. • Many midwifery programs require 1-‐year of experience as an RN prior to
acceptance into the program.
Precep7ng Student Midwives: The Most Significant Challenge to Crea7ng More Midwives
0%
10%
20%
30%
40%
50%
60%
70%
62%
38%
Most Midwifery Preceptors Are Unpaid*
Unpaid Midwifery Preceptors Paid Midwifery Preceptors
* Elaine Germano, CNM, DrPH, et al., “Factors that Influence Midwives to Serve as Preceptors: An American College of Nurse-‐Midwives Survey,” Journal of Midwifery & Women’s Health,” Vol. 59, No. 2, March/April 2014, pp. 167-‐175. ** Kathleen Fagerlund, CRNA, PhD, and Elaine Germano, CNM, DrPH, “The Costs and Benefits of Nurse-‐Midwifery Educa1on: Model and Applica1on,” Journal of Midwifery and Women’s Health, Vol. 54, No. 5, September/October 2009, pp. 341-‐350. This ar1cle reports 2008 dollars, which were inflated by the Medicare Economic Index to 2015 dollars.
Reduced produc7vity
The es1mated annual cost to a clinical site for precep1ng a single midwifery student.**
Longer work hours
ACNM Will be Developing Solu7ons and Bringing them to Policymakers
• Expansion of the Graduate Nursing Educa1on Demonstra1on?
• Tax Deduc1ons? • Medicare payment for CNMs/CMs who supervise medical interns/residents?
• Interprofessional Educa1on and GME?
Q&A