2004 Oregon Physician Workforce Survey Report of Results

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2004 Oregon Physician Workforce Survey Report of Results Presented to Oregon Department of Human Services, Health Services, Office of Medical Assistance Programs Oregon Medical Association Office for Oregon Health Policy and Research March 7, 2005 Presented by 2020 SW Fourth Avenue, Suite 520 Portland, Oregon 97201-4960 Phone 503-279-0100 Fax 503-279-0190 2004 Oregon Physician Workforce Survey Report of Results March 7, 2005 Presented to " Oregon Department of Human Services, Health Services, Office of Medical Assistance Programs " Oregon Medical Association " Office for Oregon Health Policy and Research OMAP-EQRO-105570 2004 Oregon Physician Workforce Survey Executive Summary Office of Medical Assistance Programs 3 Executive Summary Patient access to medical care in Oregon has been studied by multiple organizations in the past several years. To assist in the discussion, the Oregon Department of Human Services, Health Services, Office of Medical Assistance Programs (OMAP); the Oregon Medical Association (OMA); and the Office for Oregon Health Policy and Research (OHPR) joined forces to field a comprehensive physician workforce survey to gather valuable information on the current and future capacity of physicians in Oregon. This report is intended to present the data gathered from the 2004 Oregon Physician Workforce Survey and is one part of ... more. less.

a large, ongoing effort to study and understand patient access to the physician workforce in the state. The focus of this report is to present data on physicians 9 " changes to their practice " acceptance of insurance payer types " availability, especially of specialty care providers " concerns about professional medical liability insurance Data collection for the survey began in early September and continued through mid-October. Returned surveys were obtained from 3,508 physicians 4a response rate of 34 percent. The highlights of results from the report are grouped by topic and listed below. Practice issues " Surgical specialty physicians (33 percent) reported more often that they planed to retire in the next five years than did other specialty physicians. " Overhead costs, Medicare reimbursement, the cost and availability of liability insurance, and Medicaid/OHP reimbursement were most frequently cited by respondents as very important issues. " The most frequently cited changes to practice within next two years were increasing referral of complex cases, reducing patient care hours, increasing diagnostic procedures, stopping providing certain services, and stopping providing certain services to specific groups of patients. " More physicians have been very satisfied with their medical career overall (50 percent) than have been satisfied within the last 12 months (34 percent). Limiting acceptance of insurance payers " Of respondents, 73 percent accepted Medicare payers. Comparatively, 58 percent accepted all Medicaid/OHP managed care and 59 percent Medicaid/OHP fee-for-service payers. Medicaid payers were the most restricted; that is, physicians limited acceptance or did not accept any patients with Medicaid/OHP insurance with the greatest frequency. " The top reasons cited for limiting or not accepting any Medicare or Medicaid/OHP patients were: reimbursement, overhead costs, administrative requirements, and maintaining a balanced payer mix. 2004 Oregon Physician Workforce Survey Executive Summary Office of Medical Assistance Programs 4 Specialty care " Of those who reported ever practicing maternity care, 42 percent (226) were delivering babies at the time of the survey. " Of those who were currently delivering, 23 (10 percent) were planning to stop deliveries in the next year; 14 planned to stop all deliveries, 9 planned to stop Medicaid deliveries. " Of the maternity care physicians who stopped deliveries, 76 percent stopped more than two years ago. The top factors that influenced their decision to stop deliveries were medical liability premiums and time demands. " Of the 22 neurosurgeons responding to the survey, 15 were currently perform brain and spine surgery, and 3 performed only spine surgery; 4 perform neither brain nor spine surgery. Liability insurance " Physicians in surgical specialties reported higher premiums ($30,000 median annual premium) than other specialties ($10,000 median annual premiums for primary care and medical specialty physicians). " Obstetrics/gynecology physicians reported a median annual premium amount of $38,000 and neurosurgeons $54,000. " Physicians reported most frequently that they have increased referrals (11 percent) or definitely planned to increase (12 percent) referrals of complex cases due to their concerns about liability insurance. Nine percent had already stopped providing certain services and four percent definitely anticipated doing so. 2004 Oregon Physician Workforce Survey Table of Contents Office of Medical Assistance Programs 5 Table of Contents Executive Summary 3 Introduction 13 Background 13 Objectives and scope 15 Methodology 17 Study design 17 Survey development and administration 17 Data analysis 18 Results 21 Section 1. Respondent demographics 21 Section 2. Practice environment 25 Section 3. Acceptance of payers 39 Section 4. Specialty care 45 Section 5. Liability insurance 49 Further Research 55 Appendices Appendix A. Data comparison and categorization tables A-1 Appendix B. Tab and banner crosstabulations B-1 Appendix C. Survey instrument C-1 2004 Oregon Physician Workforce Survey List of Tables and Figures Office of Medical Assistance Programs 7 List of Tables and Figures Table 1-1. Racial distribution of survey respondents........................................................................ ...23 Table 2-1. Primary practice settings reported by respondents............................................................26 Table 2-2. Employment role distribution among respondents.............................................................27 Table 2-3. Length of licensure reported by respondents.....................................................................2 7 Table 2-4. Ownership or employment status of respondents..............................................................28 Table 2-5. Practice size distribution of respondents........................................................................ ....28 Table 2-6. Lead time to schedule non-urgent appointment reported by respondents.........................29 Table 2-7. Number of patients seen in a typical week........................................................................ .30 Table 2-8. Number of hours worked in a typical week......................................................................... 30 Table 2-9. Hours spent on administrative tasks each week................................................................31 Table 2-10. Number of on-call hours each week................................................................................ ..32 Table 2-11. Greatest source of professional satisfaction..................................................................... .37 Table 3-1. Acceptance of payer types....................................................................................... .........39 Table 3-2. Comparison of restriction by payer type......................................................................... ...40 Table 4-1. Maternity care procedures performed by physicians practicing maternity care................45 Table 4-2. Very important factors in decision to stop delivering babies, by ob/gyn and non-ob/gyn physician specialties.......................................................................................47 Table 4-3. Characteristics of neurosurgeon respondents...................................................................48 Table 5-1. Source, form, and amount of liability coverage.................................................................5 0 Table 5-2. Liability premium levels by specialty categories................................................................ 51 Table A-1. Demographic characteristics for comparison between 2004 Oregon Physician Workforce Survey sample and Oregon Board of Medical Examiners 2004 census data....................A-1 Table A-2. Oregon regions and counties within each region...............................................................A-2 Table A-3. Unique physician specialties assigned to major specialty groups.....................................A-3 Table B-1. Practice location by age of respondent........................................................................... ...B-4 Table B-2. Practice location by physician specialty ........................................................................ ....B-5 Table B-3. Distribution of physician specialties............................................................................ ........B-7 2004 Oregon Physician Workforce Survey List of Tables and Figures Office of Medical Assistance Programs 8 Table B-4. Practice setting by practice location............................................................................ .......B-9 Table B-5. Practice setting by physician specialty.......................................................................... .....B-10 Table B-6. Practice setting by length of licensure.......................................................................... ......B-11 Table B-7. Retirement plan by physician specialty........................................................................... ...B-12 Table B-8. Age by plans to retire........................................................................................... ..............B-13 Table B-9. Retirement plan by practice location ............................................................................ .....B-14 Table B-10. Physician specialty by length of licensure ....................................................................... ..B-15 Table B-11. Ownership or employment status by practice location.......................................................B-16 Table B-12. Ownership or employment status by physician specialty...................................................B-17 Table B-13. Ownership or employment status by length of licensure...................................................B-18 Table B-14. Practice size by length of licensure.............................................................................. ......B-19 Table B-15. Practice size by practice location................................................................................ .......B-19 Table B-16. Practice size by physician specialty.............................................................................. .....B-20 Table B-17. Physician specialty by lead time to appointment for new patients.....................................B-21 Table B-18. Lead time to appointment for established patients by physician specialty........................B-22 Table B-19. Lead time to appointment for new patients by practice location........................................B-23 Table B-20. Lead time to appointment for established patients by practice location.............................B-24 Table B-21. Patient caseload by length of licensure .......................................................................... ...B-25 Table B-22. Patient caseload by practice location ............................................................................ ....B-26 Table B-23. Patient caseload by physician specialty .......................................................................... ..B-27 Table B-24. Hours worked per week by gender................................................................................... ..B-28 Table B-25. Hours worked per week by age...................................................................................... ....B-28 Table B-26. Hours worked per week by practice location......................................................................B- 29 Table B-27. Hours worked per week by physician specialty..................................................................B-30 Table B-28. Hours spent on administrative tasks by practice location..................................................B-31 Table B-29. Hours spent on administrative tasks by physician specialty..............................................B-32 Table B-30. Hours spent on administrative tasks by length of licensure...............................................B-33 2004 Oregon Physician Workforce Survey List of Tables and Figures Office of Medical Assistance Programs 9 Table B-31. Hours spent on administrative tasks by gender.................................................................B-33 Table B-32. Hours on call by length of licensure.............................................................................. .....B-34 Table B-33. Hours on call by practice location................................................................................ .......B-35 Table B-34. Hours on call by physician specialty ............................................................................. ....B-36 Table B-35. Hours on call by urban or rural setting........................................................................... ....B-36 Table B-36. Importance of issues by practice location......................................................................... .B-37 Table B-37. Importance of issues by physician specialty .....................................................................B -48 Table B-38. Anticipated changes in upcoming two years by physician specialty .................................B-59 Table B-39. Anticipated changes in upcoming two years by practice location......................................B-65 Table B-40. Satisfaction with medical career in past 12 months by physician specialty ......................B-71 Table B-41. Satisfaction with medical career in past 12 months by length of licensure........................B-72 Table B-42. Satisfaction with medical career in past 12 months by practice size.................................B-73 Table B-43. Satisfaction with medical career in past 12 months by rural/urban....................................B-73 Table B-44. Satisfaction with medical career in past 12 months by practice location...........................B-74 Table B-45. Satisfaction with medical career in past 12 months by practice setting.............................B-75 Table B-46. Satisfaction with medical career in past 12 months by ownership or employment status.............................................................................................................B -76 Table B-47. Satisfaction with medical career overall by physician specialty.........................................B-77 Table B-48. Satisfaction with medical career overall by length of licensure..........................................B-78 Table B-49. Satisfaction with medical career overall by practice size...................................................B-79 Table B-50. Satisfaction with medical career overall by practice location.............................................B-80 Table B-51. Satisfaction with medical career overall by urban/rural......................................................B-81 Table B-52. Satisfaction within medical career overall by practice setting............................................B-81 Table B-53. Satisfaction with medical career overall by ownership or employment status...................B-82 Table B-54. Greatest source of professional satisfaction by physician specialty..................................B-83 Table B-55. Greatest source of professional satisfaction by practice location......................................B-84 Table B-56. Greatest source of professional satisfaction by length of licensure...................................B-85 Table B-57. Greatest source of professional satisfaction by practice size............................................B-86 2004 Oregon Physician Workforce Survey List of Tables and Figures Office of Medical Assistance Programs 10 Table B-58. Greatest source of professional satisfaction by urban/rural...............................................B-86 Table B-59. Greatest source of professional satisfaction by practice setting........................................B-87 Table B-60. Greatest source of professional satisfaction by ownership of employment status............B-88 Table B-61. Acceptance of payer type by physician specialty...............................................................B-90 Table B-62. Acceptance of patients for each payer type by practice location ......................................B-94 Table B-63. Distribution of physicians who currently deliver babies (N=226).......................................B-99 Table B-64. Maternity care procedures performed by practice location&&&&&&&&&&&&&B-100 Table B-65. Maternity care procedures performed by gender &&&&&&&&&&&&&&&&...B-102 Table B-66. Maternity care procedures performed by length of licensure&&&&&&&&&&&&B-103 Table B-67. Maternity care procedures performed by ob/gyn licensure&&&&&&&&&&&&&B-105 Table B-68. Distribution of physicians who are not currently delivering babies&&&&&&&&&...B-106 Table B-69. Time since stopping delivery of babies by ob/gyn licensure (N=303*)&&&&&&&&B-107 Table B-70. Reasons for stopping delivery of babies by ob/gyn licensure&&&&&&&&&&&&B-108 Table B-71. Liability premium amount paid by ob/gyn licensure&&&&&&&&&&&&&&&&B-111 Table B-72. Liability premium amount paid by physician specialty&&&&&&&&&&&&&&&B-111 Table B-73. Liability premium amount paid by hospital status&&&&&&&&&&&&&&&&&B-112 Table B-74. Liability premium amount paid by neurosurgery licensure&&&&&&&&&&&&&.B-112 Table B-75. Liability premium amount paid by pediatric specialty licensure&&&&&&&&&&&.B-113 Table B-76. Liability premium amount paid by high-risk specialty licensure &&&&&&&&&&&B-113 Table B-77. Actions regarding concerns about the cost or availability of liability insurance coverage&&&&&&&&&&&&&&&&&&&&&&&&&&.B-114 Table B-78. Actions regarding liability by physician specialty&&&&&&&&&&&&&&&&&.B-115 Table B-79. Actions regarding liability by physician licensure&&&&&&&&&&&&&&&&&.B-118 Table B-80. Actions regarding liability by practice location&&&&&&&&&&&&&&&&&&.B-121 Figure 1-1. Flow chart of 2004 Oregon Physician Workforce Survey mailing and returned surveys............................................................................................................... ..21 Figure 1-2. Age distribution of survey respondents........................................................................... ...22 Figure 1-3. Regional distribution of respondents 9 practice locations....................................................24 2004 Oregon Physician Workforce Survey List of Tables and Figures Office of Medical Assistance Programs 11 Figure 2-1. Specialty distribution of respondents............................................................................ ......25 Figure 2-2. Issues ranked by importance level................................................................................ .....33 Figure 2-3. Anticipated changes to practice in the next two years.......................................................35 Figure 2-4. Respondents 9 satisfaction with career overall and with career in past 12 months.............36 Figure 3-1. Financial factors rated as very important in decision to limit or restrict patient payers......41 Figure 3-2. Administrative factors rated as very important in decision to limit or restrict patient payers................................................................................................................. ....42 Figure 3-3. Patient-related factors rated as very important in decision to limit or restrict patient payers................................................................................................................. ....43 Figure 5-3. Possible practice changes regarding cost or availability of liability insurance coverage&&&&&&&&&&&&&&&&&&&&&&&&&&&&&...52 2004 Oregon Physician Workforce Survey Introduction Office of Medical Assistance Programs 13 Introduction Background The 2004 Oregon Physician Workforce Survey was administered through the joint efforts of the Oregon Department of Human Services, Health Services, Office of Medical Assistance Programs (OMAP); the Oregon Medical Association (OMA); and the Office for Oregon Health Policy and Research (OHPR). These organizations came together in the interest of collaboration and efficiency in fielding one comprehensive survey to the Oregon physician community. OMAP was interested in surveying physicians about their practice behaviors with regard to Oregon Health Plan (OHP) enrollees; OMA had planned to field a follow-up survey to its 2003 Physician Workforce Assessment survey; OHPR joined the collaboration to gather data about healthcare providers in Oregon. Joining forces has resulted in valuable information on the current and future capacity of physicians in light of the challenges of providing medical care in Oregon. Many healthcare organizations have asserted that access to medical services in Oregon is an increasing problem. 1,2,3,4 Medicare and Medicaid patients are having difficulty finding access to medical care. Physicians are leaving their practices and stopping the provision of certain services. These trends have been explained by many factors. Escalating costs of medical liability premiums have been linked to the exit from the state of specialty physicians who perform high-risk procedures and the cessation of certain high-risk procedures by these physicians. 5,6 Unfavorable fiscal conditions, coupled with the inability of physicians to subsidize their public care with higher-paying private patients, have left publicly insured clients vulnerable. Additionally, physicians are increasingly limited in their ability to absorb losses due to higher practice overhead costs from increasing malpractice premiums and other cost drivers, such as reimbursement rates and administrative requirements. 7 The results from the OMA 2003 Physician Workforce Assessment showed that about one-half of physicians limited acceptance of Medicare patients and more than 50 percent limited acceptance of Medicaid patients. 8 The most frequently cited reasons for limiting access to Medicare and Medicaid patients were the cost or availability of liability insurance and the cost of doing business. According to a national survey of physicians conducted in 2002, the percentage of physicians accepting new fee-for-service Medicare patients fell significantly, by more than 6 percentage points, from 1999 to 1 Physician workforce in Oregon 2004: a snapshot. [Oregon Health & Science University Center for Rural Health Web site]. Available at www.ohsu.edu/oregonruralhealth/workforcedata.htm. Accessed January 12, 2005. 2 Campaign to bring medical insurance reform back to Oregon gaining momentum. [ cMonday News Now d Web site of the Oregon Association of Hospitals and Health Systems]. August 9, 2004. Available at www.oahhs.org/publications/mondaynews/mn080904.htm#oahhs. Accessed January 12, 2005. 3 Smits AK, Clark EC, Nichols M, Saultz, JW. Factors influencing cessation of pregnancy care in Oregon. Fam Med 2004;36(7):490 35. 4 Oregon Medical Association. Preliminary report of the 2003 physician workforce assessment. Paper presented to the Oregon Medical Association House of Delegates, 129th Annual Meeting, April 26 327, 2003; Gleneden Beach, Oregon. 5 Smits AK, Clark EC, Nichols M, Saultz, JW. Fam Med 2004;36(7):490 35. 6 Oregon Medical Association. Preliminary report of the 2003 physician workforce assessment. Gleneden Beach, Oregon. 7 Cunningham PJ. Mounting pressures: physicians serving Medicaid patients and the uninsured, 1997 32001. Tracking Report 4Results from the Community Tracking Study No. 6. [Center for Studying Health System Change Web site]. December 2002. Available at www.hschange.com/CONTENT/505/505.pdf. Accessed January 12, 2005. 8 Oregon Medical Association. Preliminary report of the 2003 physician workforce assessment. Gleneden Beach, Oregon. 2004 Oregon Physician Workforce Survey Introduction Office of Medical Assistance Programs 14 2002. The number of physicians who accept either new fee-for-service or new managed care Medicaid patients during the same period declined by almost 9 percentage points. 9 Although low reimbursement rates have been found to be the most significant barrier to physician participation in Medicare and Medicaid, higher reimbursement rates are no longer sufficient to maintain participation in Medicaid. Some of the other barriers include the higher economic costs of providing care to Medicaid patients than to other patients, the social complexity of Medicaid patients compared with other patients, the difficulty of coordinating specialty care and tests for Medicaid patients, the relatively higher medical complexity of Medicaid patients compared with other patients, and the cumbersome administrative processes associated with Medicaid compared with other insurance payers. The medical community has asserted that physicians are retiring, leaving the state to practice elsewhere, and ceasing to offer high-risk procedures and specialties. 10,11 The specialties most often mentioned as in danger of losing physicians include obstetrics/gynecology and neurosurgery. A recent Oregon Health & Science University (OHSU) study on obstetrics care in Oregon found that more than one-half of physicians and midwives performing deliveries in the state have either stopped or plan to stop this care. Patients in rural areas and those insured by Medicaid are disproportionately affected by this trend. 12 The major reasons cited for stopping the delivery of babies were high professional medical liability premiums and low reimbursement rates. Neurology is another specialty often cited as on the decline. The 2003 OMA Physician Workforce Assessment showed that 4 percent of neurosurgeons had stopped providing all care whereas 30 percent indicated that they had stopped providing certain services. The OMA has attributed the exit of neurosurgeons and cessation of specific services to mounting liability premiums. 9 Schoenman JA, Feldman JJ. 2002 survey of physicians about the Medicare program: results of the Medicare Payment Advisory Commission 9s 2002 survey of physicians. March 2003: No. 03-01. [Medicare Payment Advisory Commission (MedPAC) Web site]. Available at: www.medpac.gov/publications/contractor_reports/Mar03_02PhysSurvRpt2.pdf. Accessed January 12, 2005. 10 High-risk specialties have higher rates of lawsuits than other specialties. Grover S. Medical malpractice damage caps: impacts of limiting noneconomic damages. July 29, 2004. [Oregon Medical Association Web site]. Available at: www.theoma.org/Files/ECON_NW_MEDMAL_REPORT.pdf. Accessed January 14, 2005. 11 Oregon Medical Association. Preliminary report of the 2003 physician workforce assessment. Paper presented to the Oregon Medical Association House of Delegates, 129th Annual Meeting, April 26 327, 2003; Gleneden Beach, Oregon. 12 Smits AK, Clark EC, Nichols M, Saultz, JW. Fam Med 2004;36(7):490 35. 2004 Oregon Physician Workforce Survey Introduction Office of Medical Assistance Programs 15 Objectives and scope The objectives of this report are to synthesize data from the 2004 Oregon Physician Workforce Survey into findings that will " provide reliable data on the current capacity of Oregon 9s medical community to deliver health care to Oregon healthcare consumers as well as forecast the future capacity of the state 9s physicians " identify barriers to physician participation in OHP, in addition to reimbursement " assess the effects of professional liability insurance costs on access to care The data identify the characteristics of physicians who do and do not participate in o OHP/Medicaid o Medicare o other lines of insurance o treating the uninsured This report is intended to present the data gathered from the 2004 Oregon Physician Workforce Survey. These findings are one part of a joint effort to study and understand patient access to the physician workforce in the state. Project stakeholders will formulate conclusions and recommendations for healthcare policies and programs in Oregon. 2004 Oregon Physician Workforce Survey Methodology Office of Medical Assistance Programs 17 Methodology Study design This survey used a cross-sectional study design to assess the current capacity of Oregon 9s medical community. Cross-sectional surveys are used to gather information on a population at a single point in time. Data obtained from descriptive cross-sectional studies are useful for planning and resource allocation. The 2004 Oregon Physician Workforce Survey data were collected using a questionnaire that utilizes both qualitative (e.g., open-ended) and quantitative (e.g., forced-choice) questions. One of the goals of the survey is to provide a comprehensive picture of the current landscape of the Oregon medical community. Therefore, the survey was administered to all physicians who provide direct patient care in Oregon and to those who have administrative roles. The source of the sampling frame was the May 2004 version of the OMA census database, which is based in part on the Oregon Board of Medical Examiners (BME) census database and includes both OMA members and nonmembers. To meet the eligibility criteria, physicians were to have an active license in Oregon and either reside in, or have a practice listed in, Oregon. 13 It is estimated that about 1,000 physicians hold Oregon practice licenses but practice elsewhere, including in the neighboring states of Washington, Idaho, and California. The survey allowed these physicians to identify themselves. Physicians deemed ineligible include medical students, retired, inactive, or deceased physicians. For the purposes of the survey, 10,354 physicians meet these criteria. Survey development and administration The OMA 2003 Physician Workforce Assessment survey was used as basis for the 2004 Oregon Physician Workforce Survey. The survey was developed by the OMA, OMAP, and OHPR and finalized after one round of cognitive testing. The cognitive testing involved a group of nine physicians, including specialists and rural practitioners. All physicians who agreed to participate in the cognitive testing provided their feedback during telephone interviews. Pretest subjects were asked to evaluate question content and questions with the potential for misinterpretation. In addition to the cognitive testing, internal pretesting with staff physicians was completed to identify questionnaire problems. The internal quality control process was completed with a focus on skip patterns and formatting issues. The survey was administered as a paper survey delivered by mail. The mail component involved a four-wave protocol, which consisted of a prenotification postcard, an initial questionnaire with cover letter and reply envelope, a reminder postcard, and a second questionnaire, cover letter and reply envelope to nonrespondents. All pieces were sent by first-class mail. An initial postcard was sent on August 15, 2004, to all physicians notifying them of the upcoming survey. On August 20, 2004, the first round of surveys was sent to 10,354 eligible physicians. Responses were tracked with a printed unique identifier on the reply envelope, to maintain respondents 9 anonymity. Approximately 150 surveys were returned for invalid addresses. These were tracked and addresses were updated as available to target for the second round of mailing. A reminder postcard was mailed to all physicians on September 1, 2004. The second round of surveys was sent to 8,560 nonrespondents on September 10, 2004. Approximately 73 percent of the 3,508 returned surveys were received from the first mailing. 13 An active license is one that is listed as unrestricted, limited, public order on file, or prior action. 2004 Oregon Physician Workforce Survey Methodology Office of Medical Assistance Programs 18 Returned surveys were processed and tracked in a database by the unique identifiers printed on the back of each reply envelope. Surveys not returned in the provided reply envelope were inspected individually by the OMPRO project manager for inclusion. If a duplicate survey was returned, it was not entered. Once the surveys were tracked and entered into a database, they were sent to data entry. The data entry person hand-entered the responses into a response database that was created with rigorous validation codes for logic and skip patterns. Initially, the lead analyst and project manager monitored data entry on a daily basis to check for entry errors and monitored the validation log for entries that failed the validation. Survey responses were entered until October 13, 2004. In order to ensure the integrity of the data used for analysis of the survey, several steps were taken to check the accuracy and completeness of the data that were entered. The validation process had two parts: " ensure that data were entered accurately by data entry staff " ensure that entered data were complete and valid Validation rules were created in the data entry database to check the validity of entered data. These validation checks determined whether data elements were missing (i.e., not entered) or fell within valid parameters. Most of the validation occurred at the time of data entry. Data analysis Descriptive and inferential statistics were used to analyze survey data, employing the Statistical Program for the Social Sciences (SPSS) software version 10.0. Frequencies and chi-square tests for n-independent samples were used to evaluate statistically significant differences among subgroups. Statistically significant variation was detected in physician response to certain survey questions. Discussion is provided in the Results section for noteworthy differences. For Sections 1 35, crosstabulations are provided in Appendix B with Pearson chi-square test statistics and p-values. Variables that are consistently used in the report are coded as follows: Physician specialties , self-designated by respondents, were grouped into five categories as defined by OMA: " primary care " medical specialties " surgical specialties " hospital-based " other 14 Practice locations were categorized into seven geographical regions based on the ZIP codes provided by respondents: " Portland metropolitan area " mid-Willamette valley " northwestern Oregon " southern Oregon 14 Responses that fell into the "other" physician specialty category included primarily psychiatry and occupational medicine. 2004 Oregon Physician Workforce Survey Methodology Office of Medical Assistance Programs 19 " eastern Oregon " southwestern Oregon " central Oregon Each region is made up of two or more Oregon counties. See Appendix A, Table A-2 for the distribution of counties within each region. Maternity care is defined as the delivery of babies, for the purposes of this analysis. Physicians were deemed maternity care providers if " they indicated that they currently perform deliveries or " they indicated that they do not currently perform deliveries, but they also indicated when they stopped delivering babies 15 Data limitations Self-reported data may be subject to error for several reasons. Retrospective self-reported responses are vulnerable to memory bias; that is, events that occurred a long time ago or the frequency of certain behaviors may be difficult to recall by respondents. Also, respondents may not have complete information to provide accurate responses. For instance, this survey asked physicians to respond to questions related to their medical practice 9s acceptance of patient groups by payer types. Physicians employed by a healthcare system may not be aware whether the system restricts access to specific groups of patients (e.g., Medicaid patients). Several factors affect the response rate achieved by a given survey, including the length and timing of the field period, the mode of interviewing, the interest of the survey content to respondents, incentives, and the total level of resources available to follow up with difficult-to-reach respondents. Despite the number of attempts to contact physicians, a substantial percentage of the surveys (66 percent) were not returned. Survey nonresponse often biases survey results because it makes the results less generalizable to the population. Gender, region, and age distributions in the survey sample were compared to census data of the Oregon physician population recorded by the Oregon Board of Medical Examiners (BME) for 2003. The comparison did not reveal any large differences between survey respondents and Oregon physicians in the BME census data. Appendix A, Table A-1 shows the comparison of demographic characteristics for the Oregon Board of Medical Examiners 2003 census data and the 2004 Oregon Physician Workforce Survey sample. 15 Four obstetrics/gynecology physicians indicated that they do not currently deliver babies but did not answer the corresponding skip pattern questions about cessation of deliveries. They were included as maternity care providers. 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 21 Results Section 1. Respondent demographics Of the 10,354 Oregon physicians who received the survey, 34 percent (3,508) returned a complete or partially completed survey. Of the returned surveys, 666 were completed by physicians who indicated that they do not provide any patient care or have an administrative role in Oregon; 320 were incomplete or unusable. 16,17 Surveys were considered complete if more than 60 percent of the ccore d questions applicable to all respondents were answered. 18 The final analytic file included 2,522 usable surveys. 19 See Figure 1-1 for a flow chart accounting for all surveys mailed. Figure 1-1. Flow chart of 2004 Oregon Physician Workforce Survey mailing and returned surveys The respondents were largely representative of all physicians in the state according to their age distribution, gender, and practice location, with the exception of physicians in the Portland metropolitan region who were slightly underrepresented by survey respondents. Respondents were 16 Physicians indicated their ineligibility in one of two ways: by checking a box in the instructions section of the survey that his or her professional time does not involve any direct patient care or administration, or by responding in survey question 8 that he or she is fully retired, or not practicing or not employed in a medical field. 17 Surveys were deemed unusable if they were returned with illegible identifiers, missing pages, or no responses (completely blank surveys). 18 Core questions include 12 315, 17 318, 20 321, 24, 27, 29 336, 39 340, 45 347, 50. Questions intended for specialty physicians only and questions that are part of skip patterns are not included in the core set. 19 To maximize the number of complete surveys in the final analytic file, the 60 percent crule d for completeness was used. Of the potentially usable surveys, 90 percent of respondents (2,535) completed 60 percent of the survey. 10,354 surveys mailed to Oregon physicians 3,508 surveys returned 6,846 surveys not returned 666 surveys returned by physicians providing neither direct patient care nor administration 320 incomplete or unusable surveys 2,522 completed surveys for analysis 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 22 predominantly white males between the ages of 40 and 59 and practiced in urban areas, either in the Portland metropolitan region or in the mid-Willamette valley. 20 Age and gender Figure 1-2 shows the distribution of ages of survey respondents. 21 Figure 1-2. Age distribution of survey respondents Of the 2,522 surveys used for analysis, 72 percent were completed by males; 28 percent by females. 22 Race and ethnicity Physicians reported that they belong to at least one of six race categories. Table 1-1 on the next page shows the distribution of responses. 20 For more information on the classification of regions as urban, see Section 2, Hours spent on administrative tasks, page 25. 21 The age distribution of physicians responding to the 2004 Physician Workforce Survey was similar to the overall age distribution of physicians in Oregon, according to the 2003 physician census kept by the Oregon Board of Medical Examiners (BME). 22 The gender distribution of physicians responding to the 2004 Physician Workforce Survey was similar to the overall gender distribution of physicians in Oregon, according to the 2003 physician census kept by the Oregon BME. 70 years and over 3% 60-69 years 14% 50-59 years 33% 40-49 years 29% Under 40 years 21% 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 23 Table 1-1. Racial distribution of survey respondents Race a Percent White 90 Asian 6 Other 2 American Indian or Alaskan Native 1 Black or African American 1 Native Hawaiian or Pacific Islander 0 a Categories are not mutually exclusive. Two percent of the respondents (52 physicians) reported their ethnicity as Hispanic or Latino. Language proficiency Respondents reported on the languages in addition to English in which they could communicate effectively for most clinical purposes. Spanish was the language most often named; 17 percent reported that they communicate effectively in this language. Russian, Vietnamese, and other languages were reported by 11 percent of the respondents. Fifteen physicians reported that they can communicate for clinical purposes in Russian; four mentioned using Vietnamese to communicate, and 261 named French, German, or other languages. Practice location Nearly three-quarters (72 percent) of physicians reported the ZIP code in which their primary practice is located. Practice locations were categorized into seven geographical regions. Each region is made up of two or more Oregon counties. Figure 1-3 shows the distribution of respondents 9 practices by region. 23 For the list of regions and counties within each region, see Appendix A, Table A-2. . 23 The regional distribution of physicians responding to the 2004 Physician Workforce Survey was similar to the overall regional distribution of physicians in Oregon, according to the 2003 physician census figures of the Oregon BME. 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 24 Southwestern 2% Eastern 4% Southern 11% Northwestern 3% Mid-Willamette Valley 23% Central 9% Portland Metro 48% Figure 1-3. Regional distribution of respondents 9 practice locations See Appendix B, Tables B-1 and B-2 for a crosstabulation of practice location by age of respondent and physician specialty. 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 25 Medical specialties 21% Surgical specialties 11% Hospital-based 16% Other 8% Primary care 44% Section 2. Practice environment Respondents provided information on their practice environment, including the physician specialty, retirement plans, employment role, ownership status, length of licensure, practice size, lead times for patient appointments, workload, important issues, anticipated changes, and satisfaction with their career. Physician specialty Nearly all of the respondents that completed the survey reported their specialty (2,506). The responses were combined into five specialty categories used by OMA in the 2003 Physician Workforce Assessment. A brief description of the category and major specialty types follows: " Primary care includes internal medicine, family practice, pediatrics, and obstetrics/gynecology. " Medical specialties include internal medicine specialties, ophthalmology, and urology. " Surgical specialties include general surgery and surgical specialties, such as orthopedics and neurosurgery. " Hospital-based specialties include anesthesiology, emergency medicine, pathology, and radiology. " Other specialties include psychiatry and occupational medicine. Figure 2-1 shows the distribution of the five major specialty categories among survey respondents. Figure 2-1. Specialty distribution of respondents For a full list of the 60 reported physician specialties and the number and percent of respondents reporting each specialty, see Appendix B, Table B-3. 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 26 A small percentage of respondents reported having a pediatric focus within their specialty: 5 percent of respondents in medical specialties and 3 percent of those in surgical specialties said that their practice included pediatrics. 24 Among the respondents that reported hospital-based specialties, 36 percent are emergency medicine physicians. Practice setting The majority of physicians reported that their primary practice setting is in a private, for-profit clinic or a hospital. 25 Table 2-1 shows the distribution of practice settings reported by respondents. Table 2-1. Primary practice settings reported by respondents Practice setting a Percent Clinic, private, for-profit 54 Hospital 43 Clinic, private, not-for-profit 12 Clinic, public 5 Other 4 a Categories are not mutually exclusive. See Appendix B, Tables B-4 through B-6 for a crosstabulation of practice setting by respondents 9 practice location, physician specialty, and length of licensure. Retirement plans More than three-quarters of the respondents (78 percent) reported that they plan to retire more than five years from now; 22 percent said they plan to retire some time in the next five years. There is statistically significant variation by age in reported retirement plans. As expected, older physicians reported plans to retire sooner than younger physicians. The majority of physicians 60 to 69 years old (74 percent) plan to retire in the next five years, as do 73 percent of physicians 70 years and older. There also appears to be significant difference by specialty, with a higher percentage of physicians in surgical specialties reporting plans to retire in the next five years (33 percent) than those in other specialties. For a crosstabulation of retirement plans by physician specialty, age, and practice location, see Appendix B, Tables B-7 through B-9. Employment role All of the respondents who practice or have administrative roles reported that they have one or more employment roles. Physicians who were fully retired 4neither practicing clinically nor 24 The survey did not specifically ask physicians to state whether their specialty included pediatrics. The number of respondents who did not mention pediatrics, but do, in fact, see children in their practice, is unknown. 25 The survey instructs respondents to consider the location at which they spend the greatest amount of time in direct patient care as the primary practice location. 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 27 employed in an administrative role 4did not complete the survey. Table 2-2 shows the distribution of employment roles among respondents. Table 2-2. Employment role distribution among respondents Employment role a Percent Clinical practice 96 Teaching 19 Administration 12 Research 9 Resident/fellow 2 Semi-retired 0 b a Categories are not mutually exclusive. b Semi-retired physicians that completed the survey were less than 1 percent of all respondents (9 respondents). Length of licensure The majority of physicians who responded to the survey (89 percent) reported that they have had a medical license in any state, including Oregon, for six or more years. Table 2-3 shows the distribution of respondents 9 length of licensure. Table 2-3. Length of licensure reported by respondents Length of licensure Percent Less than 2 years 2 2 35 years 9 6 310 years 15 11 320 years 29 More than 20 years 45 See Appendix B, Table B-10 for a crosstabulation of physician specialties by length of licensure. Ownership or employment status Physicians reported on their ownership or employment status at their primary practice site. Table 2-4 on the next page shows the distribution of responses. 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 28 Table 2-4. Ownership or employment status of respondents Ownership or employment status Percent a Full or part owner of practice 55 Employee of practice or health system 35 Independent contractor 7 Other 2 Volunteer 1 a Percents do not add to 100 percent due to rounding. For respondent ownership or employment status by practice location, physician specialty, and the length of licensure, see Appendix B, Tables B-11 through B-13. Practice size Roughly one-third of respondents (35 percent) reported that they practice in a large group practice (10 or more physicians). Table 2-5 shows that physicians who work in solo, small, and medium group practices are approximately evenly distributed. Table 2-5. Practice size distribution of respondents Practice size Percent Large group practice (10 or more physicians) 35 Solo practice (1 physician) 24 Small group practice (2 34 physicians) 22 Medium group practice (5 39 physicians) 20 There is significant variation in respondents 9 primary practice size by practice location, physician specialty, and length of licensure. Medium-sized practices have higher percentages of physicians licensed for less than 10 years than other practice size categories. More than one-half of solo practice physicians have been licensed for more than 20 years. The majority of large group practices report a Portland metropolitan or Mid-Willamette Valley practice location (83 percent). Surgical specialty physicians comprise 18 percent of solo practices, which is proportionally greater than their representation in other practice sizes ( § 2 =243.582, p<0.0001). Appendix B, Tables B-14 through B-16 show the crosstabulations of practice size by length of licensure, practice location, and physician specialty. Lead time for scheduling a non-urgent appointment Respondents reported a wide range for the number of days required for new patients to schedule a non-urgent appointment. Reported lead times for appointments were combined into four roughly equivalent categories. Although the average lead time for a new patient appointment is 17 days, 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 29 Table 2-6 shows that nearly one-half (45 percent) see new patients within 7 days. 26 The majority of respondents reported seeing established patients within 7 days (66 percent); the average lead time for an appointment for established patients is 9 days. 27 Table 2-6. Lead time to schedule non-urgent appointment reported by respondents Days to schedule a non-urgent appointment by patient type Percent a New patients 0 37 days 45 8 314 days 22 15 330 days 21 More than 30 days 12 Established patients 0 37 days 66 8 314 days 19 15 330 days 13 More than 30 days 3 a Percents do not add to 100 percent due to rounding. Primary care physicians reported seeing new patient within 7 days more frequently than specialty physicians. More than one-half of primary care physicians (54 percent) reported that, on average, new patients were seen within seven days of making an appointment. New-patient appointments within seven days of scheduling were reported by 31 percent of medical specialty physicians and 43 percent of surgical specialty physicians. For established patients, 76 percent of primary care physicians reported an average lead time within seven days, compared with 48 percent of medical specialty physicians and 59 percent of surgical specialty physicians. For a crosstabulation of lead times for appointments for new and established patients by physician specialty and practice location, see Appendix B, Tables B-17 through B-20. Caseload Total caseload categories were determined by examining the distribution of reported numbers of new and established patients seen in a typical week. Caseload levels were rolled up into five categories and a sixth category of zero patients for respondents who do not routinely have a fixed panel of patients. 28 See Table 2-7 for the distribution of the number of patients seen in a typical week. 26 A total of 1,806 respondents reported lead time for an appointment for new patients: the minimum reported lead time for an appointment for new patients was 0 days; maximum, 365; the standard deviation is 24 days. 27 A total of 1,791 respondents reported lead time for an appointment for established patients: the minimum reported lead time for an appointment for established patients is 0 days; maximum, 365; the standard deviation is 16 days. 28 A total of 2,522 respondents reported the number of new and established patients seen in a typical week. The minimum reported number of patients was 0 patients; maximum, 800; the standard deviation is 47 days. 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 30 Table 2-7. Number of patients seen in a typical week Number of patients seen in a week Percent a 0 patients 15 1 325 patients 17 26 350 patients 19 51 375 patients 19 76 3100 patients 19 More than 100 patients 12 a Percents do not add to 100 percent due to rounding. Differences in caseload were detected by practice location, specialty, and length of licensure. Physicians with practices outside the Portland metropolitan region reported seeing more than 100 patients in a typical week more often than physicians in the Portland metropolitan region. As might be expected, primary care physicians reported heavier patient caseloads than physicians in other specialties. Primary care physicians more often reported seeing 76 or more patients in a typical week (47 percent). See Appendix B, Tables B-21 through B-23 for crosstabulations of patient caseload by length of licensure, practice location, and physician specialty. Number of hours worked The number of hours a respondent worked was determined by adding the number of hours per week in direct patient care across primary and secondary practice locations. 29 If a respondent reported specialties in addition to a primary specialty, these hours were included. Respondents reported a wide range for the number of hours worked each week; the average number of hours worked in a typical week was 44. 30 Most respondents work full time or more than full time in a typical week. Table 2-8 shows that two-thirds (66 percent) of respondents work 40 or more hours each week. Table 2-8. Number of hours worked in a typical week Number of hours worked each week Percent Less than 20 hours per week 11 20 339 hours per week 23 40 360 hours per week 41 More than 60 hours per week 25 29 Work hours were defined to include time spent on patient record keeping, patient-related office work, and travel time connected with seeing patients. Training, teaching, research time, hours on call when not actually working, and travel between home and work were not included. 30 A total of 2,520 respondents reported number of hours per week. The minimum reported average number of hours worked per week was 0; maximum, 160; the standard deviation is 21. Two physicians reported working more than 168 hours in a week, which exceeds the possible number of hours in a week. 2004 Oregon Physician Workforce Survey Results Office of Medical Assistance Programs 31 Significant differences were found in the number of hours worked in a typical week by gender, location of practice, physician specialty, and age. Female physicians (45 percent) reported working fewer than 40 hours a week more often than male physicians (30 percent). Physicians practicing outside of urban areas reported work weeks of greater than 60 hours more frequently than physicians practicing within urban areas. 31 Physicians in surgical specialties reported working more than 60 hours a week (46 percent) more often than physicians in other specialties. Physicians older than 60 years of age reported working fewer hours each week than their younger counterparts. See Appendix B, Tables B-24 through B-27 for a crosstabulation of hours worked each week by gender, age, practice location, and physician specialty. Hours spent on administrative tasks Physicians reported on the number of weekly hours spent on administrative tasks related to direct inpatient and outpatient care: for example, charting, phone calls, referrals, and paperwork. Physicians spent, on average, 10 hours a week on administrative tasks. 32 Table 2-9 shows the distribution of responses. Table 2-9. Hours spent on administrative tasks each week Hours spent on administrative tasks each week Percent Less than 5 hours 20 5 39 hours 29 10 314 hours 28 15 319 hours 10 20 or more hours 13 Significant differences were found in the amount of time spent in administrative tasks by location of practice, physician specialty, and length of licensure. Physicians in southern Oregon more often reported spending more than 20 hours a week on administrative tasks (21 percent) than physicians in other areas of the state. Likewise, physicians likely to have a fixed patient panel 4e.g., those in primary care, medical specialties, and surgical specialties 4reported spending more hours performing administrative tasks than physicians in hospital-based and other specialties. Appendix B, Tables B-28 through B-31, show the number of hours spent on administrative tasks by practice location, physician specialty, length of licensure, and gender. 31 This analysis uses t

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