The State of Physical Medicine and Rehabilitation in Iowa: 2000-2005

Abstract

Background:

The purpose of this study was to to describe the practice of physical medicine and rehabilitation within Iowa from 2000-2005 by conducting a survey of the 30 practicing physical medicine and rehabilitation physicians in Iowa.

Results:

Nine of 15 respondents completed medical school or residency training in midwest states. Physiatrists expressed numerous concerns including poor reimbursement, increasing malpractice costs, and difficulty recruiting physiatrists to Iowa. Iowa is ranked 49th in physical medicine and rehabilitation physicians per capita population. It also ranks 50th in Medicare payments per enrollee, yet is ranked fourth in the nation for percentage of citizens over the age of 65.

Conclusions:

Recruitment of physical medicine and rehabilitation physicians should be tailored toward resident physicians completing training programs from midwest states. Retention of Iowa physiatrists, due to Iowa's lack of a physical medicine and rehabilitation residency training program, low Medicare reimbursement, and high percentage of patients over the age of 65, may lead to a "perfect storm" public health crisis for Iowans regarding the availability of future physical medicine and rehabilitation services.

INTRODUCTION

Physical medicine and rehabilitation is the medical specialty focused on the diagnosis and treatment of patients with acute and chronic neurologic and musculoskeletal injuries and diseases. Patients who may need physical medicine and rehabilitation care include those with brain injuries, strokes, spinal cord injuries, peripheral nerve injuries, or other bone, muscle and joint problems that are not likely to require surgery. These patients are typically treated in an acute inpatient rehabilitation unit where a multidisciplinary team of physical therapists, occupational therapists, speech therapists, rehabilitation nurses, and medical social workers are readily available. In the outpatient setting, physiatrists (physicians trained in physical medicine and rehabilitation) treat a diverse group of patients with chronic injury and disease such as osteoarthritis, spine and musculoskeletal pain, sports injuries, osteoporosis, neuromuscular injuries, and other disabling problems. Physiatrists have a different range of expertise than an orthopaedic surgeon, rheumatologist, or a non-physician provider such as a physical therapist or chiropractor. These skills can include knowledge about and referrals for specific physical therapy treatment approaches, prescription medication management, spinal and peripheral joint injection techniques, osteopathic manipulative treatments, orthotic or prosthetic bracing options, and referral to orthopaedic or neurosurgical colleagues. Physiatrists are experts in the interdisciplinary team model of care and are frequently the leaders of physician-directed rehabilitation services.

Many Iowa physiatrists have been recruited by local hospitals or health organizations to be medical directors for their inpatient rehabilitation units. Until the 1990s, few physiatrists had only outpatient practices with no inpatient responsibilities. Some had specialized in outpatient procedures including acupuncture or electrodiagnostic medicine. Historically, outpatient musculoskeletal care in Iowa had been provided by orthopaedic surgeons. Orthopaedic surgeons trained in Iowa were taught that they must be knowledgeable about not only the surgical aspects of musculoskeletal care but also all of the non-surgical aspects. Patients in Iowa also sought out non-physician health care providers including physical therapists and chiropractors. Both specialties have generous state practice acts allowing them to care for many patients with spine or musculoskeletal conditions without direct referral from a physician.

Until 2000, the University of Iowa did not have any faculty members trained in physical medicine and rehabilitation to encourage their medical students to enter this specialty. At the osteopathic medical school at Des Moines University, faculty members in physical medicine and rehabilitation had some success in promoting this specialty, but because there was no residency training program in Iowa, all their interested medical students needed to seek residency training elsewhere. The nearest midwest programs are in Minnesota, Wisconsin, Illinois, and Missouri. There has never been a study of physiatrist recruitment back into Iowa following completion of their training. A study of Iowa physiatrists conducted in 2002 by Jung and Chen concluded that physiatrists trained in the midwest are most likely to develop a stable, diverse physiatry practice in Iowa.¹ Facilities trying to recruit physiatrists should tailor their efforts toward residents or fellows from midwestern physiatry programs.

We wanted to explore what other factors could improve recruitment of physiatrists to Iowa. High malpractice rates and poor reimbursement are factors that may be contributing to difficulty with recruitment. In the prior Jung/Chen study, a survey of 20 physiatrists indicated that malpractice rates increased by $1611 (>20 percent) over the previous year, and one of 20 physiatrists had limited his or her Medicare practice. Five others indicated they planned to limit their Medicare practice due to poor reimbursement. The possibility that physiatrists may be limiting their Medicare practice was discouraging since there is a sizable percentage of Iowans over age 65, many of whom have conditions such as stroke, spine pain and injury, osteoarthritis, osteoporosis, chronic pain, and debility which can be treated by physiatrists. Therefore, the recruitment of physiatrists would benefit the public health of Iowans. Physiatrists could provide medical care above that which is currently provided by orthopaedic surgeons, physical therapists, or chiropractors for the above conditions.

A follow-up study was thus developed to reexamine physiatrists' training, practice demographics, concerns, and strategies to improve recruitment and retention of Iowa physiatrists.

METHODS

A more extensive follow-up questionnaire was sent to the 30 Iowa physiatrists in 2003. Questions covered practice setting and hours, patient demographics, additional qualifications, clinical expertise, malpractice costs, Medicare participation, and whether members felt there is a shortage of physiatrists in Iowa.

The questionnaire also asked for the reasons they had moved to Iowa, including whether they had lived in Iowa before, had completed medical school or residency training in Iowa, had lived in the midwest before and which state, had completed medical school or residency in the midwest, or had family who lived in Iowa before, and requested job details, financial packages offered, and "other." If they were currently looking to move their practice out of Iowa, they were asked to indicate how important family needs, quality of life, the financial package, and job details (such as too much managed care or poor relationships with other clinicians) were figuring into their decision. If they were planning to keep their practice in Iowa, they were asked how much these factors had enticed them to stay.

The participants were asked to rank their top five of these twelve concerns: on-call responsibilities, hospital administrative issues, practice management, continuing medical education (CME), high workload, low workload, recruiting new physiatrists, retention of current physiatrists, costs of malpractice insurance, reimbursement, recertification, and other. They were also asked if they felt in control of making decisions on their practice's personnel, efficiency, and overhead, and where they obtain CME credits.

RESULTS

Thirty surveys were sent to physiatrists in Iowa. Results are summarized in Table 1.

TABLE 1. Summary of Iowa Physiatrists Survey, 2003.

Fifteen surveys were completed yielding a 50 percent response rate. Six were from solo practices, six from multispecialty practices, one from a hospital practice, and two from university practices. The average time in Iowa was 9.5 ± 4.8 years (range 2-20), with the over-all time as a practicing physiatrist 11.5 ± 6.2 years (range 3-25). On average, 37 percent of their practices were inpatient, and 63 percent were outpatient. The average age of responding physiatrists was 45 ± 7 years old.

Sixty-six percent of patients were referred to physiatrists by colleagues in orthopaedic surgery, neurosurgery, neurology, rheumatology, and medicine; six percent were referred by physical therapists. Self-referrals from the community accounted for 24 percent of the patient population, and approximately six percent were referred from other sources such as workers' compensation carriers, attorneys or other non-physician providers.

Seven physiatrists had completed their medical school training in Iowa, two from the allopathic medical school and five from the osteopathic medical school. Two others completed medical training in other midwestern states (Illinois and Ohio). Five respondents trained in Minnesota, three in Illinois, one in Kansas, and one in Michigan. Other respondents who completed their training in non-midwestern states were from Washington, California, New York, and Pennsylvania.

When respondents were asked why they chose to move to Iowa, six had lived in Iowa earlier in their lives, six specifically stated that they had medical school training in Iowa, five had lived in the midwest before, and six had family in Iowa.

The Iowa physiatrists were asked to rank their top five out of a list of 12 possible concerns. These concerns were given five points if ranked #1, four points if ranked #2, three points if ranked #3, two points if ranked #4 and one point if ranked #5. The greatest concerns indicated by the physiatrists included poor reimbursement (41 points), high malpractice costs (34 points), practice management issues (26 points), difficulty recruiting (24 points), hospital administration issues (17 points), continuing medical education (16 points), high work load (16 points), call responsibilities (12 points) and recertification (9 points).

Self-reported payer mix included, on average, 38 percent patients from Medicare, 38 percent from commercial insurance, six percent self pay, and 12 percent Medicaid. Three respondents were considering limiting their Medicare practices. In 2002, the average percentage of patients on Medicare was 35 percent ± 18.0 percent (range 5-60). One practitioner indicated that they limited their Medicare practice. Five others indicated that they planned to limit their Medicare practice. Only one Iowa physiatrist participated in the now defunct State Papers Program which has been replaced by the IowaCare program.

Malpractice rates continue to be a concern among Iowa physiatrists. Many have had a substantial increase in premiums, to an average of $9000 ± 1100 per year among six respondents. Their malpractice rates had increased from $7000 ± 1000 per year over the preceding year. In 2002, eight respondents reported an average increase in malpractice insurance premiums of 30 percent. No one reported rate reductions.

Physiatrists reported, on average, working 52 ± 14 hours per week (range 40-90) in 2004, which was a slight increase from 49 ± 8 hours (range 35-70) in 2002.

In 2004, physiatrists performed an average of 12 new outpatient consultations per week, four new inpatient consultations, zero ER visits, three EMGs, one acupuncture, 33 follow-up visits, 24 follow-up consultations/rehabilitation unit visits, two spinal injections, seven peripheral injections, and seven manipulation procedures. They also spent six hours performing administrative work. Three supervised medical students or residents. The average time before seeing a scheduled new patient was 10.4 ± 9.6 days (range 1-30).

When respondents were asked if they were recruiting additional physiatrists, five said yes, three stated they planned on recruiting in the near future, and five did not plan on recruiting for at least five years. When asked whether there was a shortage of physiatrists in the United States, only five said yes. When asked whether physiatry was a specialty in shortage in Iowa, six stated yes and eight stated no.

DISCUSSION

Physical Medicine and Rehabilitation and State Demographics

The medical specialty of physical medicine and rehabilitation has exhibited lopsided growth throughout the country. Some parts of the country have many physiatrists per capita and others have many fewer practicing physiatrists. According to a 2001 Iowa Medical Society study (Table 2), the District of Columbia has one physical medicine and rehabilitation physician per 16,395 people and ranks first in the nation in having the highest number of physiatrists per capita. Mississippi has only one physiatrist for 158,874 people and is ranked 51 among the states and the District of Columbia. Oklahoma is ranked 50 at 119,641 per capita. Iowa is ranked 49 and has one physiatrist per 112,768 people.

TABLE 2. Physical Medicine & Rehabilitation Physicians per capita, its Relation to Residency Training Programs, Ranking of Medicare Payments per enrollee, and Ranking of States with Older Citizens.

State or District	Rank	Persons per PM&R Physician2	Number of PM&R Residency Training Programs3	Medicare Payments per Enrollee by State4	Rank of Medicare by State	Percent of population >65 yo5	Rank of States with population >65 yo
Top 10 States in PM&R physicians per capita
District of Columbia	1	16,395	2	NA	NA	12.2	NA
New York	2	21,299	15	$7,489	3	12.9	24
New Jersey	3	24,959	2	$5,702	18	13.2	18
Pennsylvania	4	27,772	5	$7,226	4	15.6	2
Delaware	5	30,638	0	$4,387	40	13	23
Massachusetts	6	34,979	3	$6,202	11	13.5	12
Washington	7	36,769	1	$4,303	41	11.2	42
Wisconsin	8	36,775	2	$5,031	30	13.1	20
Hawaii	9	37,183	0	$4,266	43	13.3	16
Minnesota	10	38,050	2	$4,750	35	12.1	32
Bottom 11 States in PM&R physicians per capita
Arkansas	41	72,830	1	$5,478	21	14	9
Florida	42	73,423	2	$7,603	2	17.6	1
Georgia	43	77,830	1	$4,713	36	9.6	48
Rhode Island	44	81,512	0	$6,675	7	14.5	6
Nebraska	45	81,907	0	$5,367	24	13.6	11
South Carolina	46	84,628	0	$5,791	16	12.1	31
Alabama	47	91,202	1	$6,144	12	13	21
New Mexico	48	107,702	0	$3,689	49	11.7	38
Iowa	49	112,768	0	$3,414	50	14.9	4
Oklahoma	50	119,641	0	$4,590	37	13.2	19
Mississippi	51	158,874	0	$5,055	29	12.1	34

The under-use of physiatrists to treat musculoskeletal conditions in Iowa may be related to the fact that physical therapists have direct access and independent practices in Iowa. Iowa Code Title IV, chapter 148A.1, states, "Physical therapy evaluation and treatment may be rendered by a physical therapist with or without a referral from a physician, podiatric physician, dentist, or chiropractor." In this study, only six percent of referrals to Iowa physiatrists came from physical therapists, indicating that only a small number of physical therapists refer patients for additional rehabilitation medicine care. There is clearly a well-established role for the rehabilitation physician in the care of patients with complex neuromusculoskeletal problems. It is possible that many physical therapists view their clients as their own and may not want to upset the referring physicians by making a referral to a physiatrist. There is also a strong chiropractic community within Iowa, and many patients have previously sought treatment for musculoskeletal conditions from a physical therapist or a chiropractor rather than a physical medicine and rehabilitation physician.

Iowa has two Level I trauma units, one located at the University of Iowa Hospitals and Clinics, and one in Des Moines. There are also nine comprehensive inpatient rehabilitation units in Iowa, all located in community hospitals. The University of Iowa does not have an inpatient rehabilitation unit and relies upon community hospital-based inpatient rehabilitation units to provide such coverage. Early physiatrist involvement in rehabilitation for brain-injured and spinal cord-injured patients is a requirement to maintain American College of Surgeons certification for trauma units. If Iowa could recruit more physiatrists, it is likely that additional trauma rehabilitation care could be provided to Iowans, and rehabilitation could be provided closer to a patient's home town following medical stabilization.

Physical Medicine and Rehabilitation and Medical Schools

Today, medical student knowledge about physiatry is growing. Five medical students from the University of Iowa Carver College of Medicine are completing their physical medicine and rehabilitation residency training at institutions in Washington, Illinois, Utah, and Ohio. Although the first residency training program in physical medicine and rehabilitation was started in the midwest at the Mayo Clinic in 1936, today there are still several midwest states without physiatry residency training programs, including Iowa, Nebraska, South Dakota, and North Dakota. There are 12 physical medicine and rehabilitation residency programs in states adjacent to Iowa, including two in Minnesota, two in Wisconsin, five in Illinois, and two in Missouri. If Iowa had a residency training program in physical medicine and rehabilitation, it is possible that Iowa would be able to recruit these graduates and possibly retain more physiatrists in the future. There are only five residency training programs in those states ranked #41-51 in number of physiatrists per capita, whereas there are 32 such residency training programs in those states that are ranked in the top ten. Wisconsin and Minnesota have two residency training programs and are ranked eighth and tenth, respectively. Nebraska, ranked at 45, is the only other midwest state in the bottom ten, and it also lacks a residency training program in physical medicine and rehabilitation. Many of the other states in the bottom ten are in the south. There is only one physiatry residency training program among the states ranked #47-51.

2005 Update

Since 2000, when there were 26 physiatrists in Iowa, ten new physiatrists have moved to Iowa, five have left, and one retired yielding a total of 30 physiatrists in Iowa in 2005. A retrospective review was done using an internet search to look at the medical school and residency training backgrounds of those physiatrists who came to Iowa after 2000 and are still practicing in Iowa. Six out of seven had medical school or residency training in Iowa or another midwestern state. This data supports the conclusion that physiatrists who have trained in the midwest are most likely to be recruited to an Iowa physiatry practice.

What This Means for Iowa

Iowa ranks 49 out of the 50 states and District of Columbia in the number of physical medicine and rehabilitation physicians per capita population. There is nearly a ten-fold difference in the number of physical medicine and rehabilitation physicians per capita between the top and bottom states. Many of the early academic departments of physical medicine and rehabilitation originated at institutions in the top ten states, such as the Rusk Institute of Rehabilitation in New York, the Kessler Institute of Rehabilitation in New Jersey, and Temple University in Pennsylvania. Citizens from states like Washington and Minnesota with strong, reputable academic departments in physical medicine and rehabilitation also enjoy the benefits of improved access to physical medicine and rehabilitation physicians and improved care of the neurologic and musculoskeletal conditions they treat. Efforts to bolster the Department of Orthopaedics and Rehabilitation at the University of Iowa could improve patient access to rehabilitation physicians available at a tertiary care center. Iowa also has one of the largest percentages of citizens over the age of 65, at 14.9 percent, ranked fourth in the nation. Most citizens over the age of 65 are eligible for Medicare and are more likely to suffer from conditions such as osteoarthritis, stroke, osteoporosis, spine pain, and general debility. Physiatrists are specifically trained to treat these types of conditions.

CONCLUSIONS

Examination of the number of physiatrists per capita population served indicates that more physiatrists are needed in Iowa. Further recruitment efforts should be tailored toward residents completing physical medicine and rehabilitation residency training programs in other midwestern states. Recruitment of physiatrists to Iowa is essential to improve Iowa's ability to provide comprehensive rehabilitative medical care to patients with neuromusculoskeletal conditions including stroke, spinal cord injury, spinal pain and injury, musculoskeletal deconditioning, osteoporosis, and trauma. There may still remain significant challenges in the retention of Iowa physiatrists due to low Medicare reimbursement and the high percentage of patients over the age of 65. These factors are now causing a scarcity of physical medicine and rehabilitation services but could develop into a public health crisis "perfect storm" in the years to come.