The Debt Burden of Entry-Level Physical Therapists.

BACKGROUND: The growing student debt of physical therapists entering the workforce, coupled with the growth in projected need, raises concerns about where and how entry-level physical therapists will practice and if these choices will be affected by their debt burden. OBJECTIVE: The purpose of this study was to identify the debt profile of entry-level physical therapists and explore relationships between student debt and clinical practice setting choices. METHODS: This study utilized a cross-sectional survey design to identify debt profiles and explore relationships between student debt and the clinical practice choices of entry-level physical therapists. RESULTS: The mean debt-to-income ratio based on the total reported educational debt was 197% (93%). The most frequently reported debt range for doctor of physical therapy (DPT) debt and total educational debt was $100,000 to $124,999. Despite the setting itself being rated as the most important factor (83%), 28% of participants reported debt as a barrier to their desired practice setting. In addition, when considering job choice overall, 57% of the participants reported that their student debt has had an effect on their decision. LIMITATIONS: This study is limited by its small sample size, originating from 1 state, and being taken by convenience from a special interest group. Data were collected via an anonymous survey, which increases the risk of selection bias. In addition, there are further personal, family, and institutional characteristics that were not collected in this study, which may influence the interaction between student debt and clinical practice choices. CONCLUSION: The results of this study suggest that practice setting choice may be affected by physical therapist student debt, and student debt may be a barrier overall to practice and career choices in physical therapy.

The role of financial factors in the mobility and location choices of General Practitioners in Australia.

BACKGROUND: The geographic distribution of health workers is a pervasive policy concern. Many governments are responding by introducing financial incentives to attract health care workers to locate in areas that are underserved. However, clear evidence of the effectiveness of such financial incentives is lacking. METHODS: This paper examines General Practitioners' (GPs) relocation choices in Australia and proposes a dynamic location choice model accounting for both source and destination factors associated with a choice to relocate, thereby accounting for push and pull factors associated with job separation. The model is used to simulate financial incentive policies and assess potential for such policies to redistribute GPs. This paper examines the role of financial factors in relocating established GPs into neighbourhoods with relatively low socioeconomic status. The paper uses a discrete choice model and panel data on GPs' actual changes in location from one year to the next. RESULTS: This paper finds that established GPs are not very mobile, even when a financial incentive is offered. Policy simulation predicts that 93.2% of GPs would remain at their current practice and that an additional 0.8% would be retained or would relocate in a low-socioeconomic status (SES) neighbourhood in response to a hypothetical financial incentive of a 10% increase in the earnings of all metropolitan GPs practising in low-SES neighbourhoods. CONCLUSION: With current evidence on the effectiveness of redistribution programmes limited to newly entering GPs, the policy simulations in this paper provide an insight into the potential effectiveness of financial incentives as a redistribution policy targeting the entire GP population. Overall, the results suggest that financial considerations are part of many factors influencing the location choice of GPs. For instance, GP practice ownership played almost as important a role in mobility as earnings.

Where Do Pediatric Dental Residents Intend to Practice? Exploring the Influence of Loan Repayment Programs and Other Factors.

The high cost of dental education and consequent loan burdens contribute to the shortage of pediatric dental providers in rural areas (RAs). Economic incentives are meant to recruit practitioners to RAs. The aim of this study was to assess the ability of government subsidized loan repayment programs (GSLRPs) to recruit pediatric specialists to practice in RAs. A 26-item questionnaire was emailed to all 921 pediatric dental residents across the U.S. in 2015 for a cross-sectional study of factors influencing their choice of practice location. The instrument included information about GSLRPs, enabling the study to serve as a quasi-experiment on the level of funding needed to make GSLRPs effective. A total of 169 residents responded, for an 18% response rate; 74% of respondents were women and 86% had student loan debt. Among the respondents, 40.6% said they would like to practice in RAs, but only 4.1% actually intended to do so. Over one-third initially reported interest in GSLRPs for practicing in RAs. However, after being informed that the average GSLRP is $30,000 annually, one-third of those lost interest. Although 14.2% said no amount would convince them to consider practice in an RA, over half (53.3%) indicated willingness to consider it if the GSLRP were $40,000-$60,000. These results suggest that current GSLRP levels are insufficient to induce pediatric dentists to practice in RAs.

Financial Compensation For Hepatologists in Different Practice Settings.

Several governmental agencies and private organizations monitor data on relative value units (RVUs) and salary earned by various medical specialists. There are currently no data that define the RVU production and salary earned by hepatologists. A web-based survey that queried the number of patients that a hepatologist cares for, RVU production, and salary support was sent to 2,587 members of the American Association for the Study of Liver Diseases. A total of 391 members completed the survey, 229 of whom reported spending more than 75% of their time in clinical practice/direct patient care and served as the basis for this analysis. The mean age of the cohort was 48 years, 77% were male, and all regions of country were represented. Their mean duration in clinical practice was 11.4 years. Hepatologists worked in four practice settings: university hospital with a liver transplant (LT) program (UHLT, n = 148), non-university hospital with LT (nonUHLT, n = 35), university hospital with no LT (UHnoLT, n = 29), and community practice (CP, n = 17). The average number of patients seen monthly was lowest for hepatologists at a UHLT (154) and highest for those in CP (293). Hepatologists at LT programs saw the highest percentage of patients with liver disease (91% of encounters), performed the fewest endoscopic procedures (12%-17%), but received the highest compensation/RVU ($68-$85) compared with hepatologists at UHnoLT and CP ($44-$63/RVU). The mean base salary for all hepatologists with fewer than 5 years of experience was $273,507, and this increased to $347,656 for those with more than 5 years of experience. We concluded that hepatologists at LT centers are compensated at much higher rates per encounter than in other practice settings. This may be due to salary subsidies provided by the UHLT and nonUHLT to their hepatologists.

Impact of the workforce distribution on the viability of the osteopathic profession in Australia: results from a national survey of registered osteopaths.

Background: Workforce distribution has an important influence on the quality of healthcare delivered in a region, primarily because it impacts access to health services in the community and overall health equity in the population. Distribution of osteopaths in Australia does not appear to follow the Australian population with the majority of osteopaths located in Victoria. The implications of this imbalance on the osteopathic workforce have not yet been explored. Methods: A secondary analysis of data from a survey of 1531 members of Osteopathy Australia in 2013. The analysis focused on the practice and occupational characteristics associated with practice locality. Results: The survey was completed by a representative sample of 432 osteopaths. Respondents practicing outside Victoria were more likely to report higher income across all income brackets, and were less likely to report a preference for more patients. Conclusions: The Australian osteopathic profession should examine the issue of imbalanced workforce distribution as a priority. The results of this study are worth considering for all stakeholders as part of a coordinated approach to ensure the ongoing health of the Australian osteopathic workforce.

Influence of student debt on health career location and specialty.

INTRODUCTION In New Zealand (NZ), there are shortages of health professionals in rural areas and in primary care. AIM This study aims to examine the association of student debt levels of medical, nursing, pharmacy and optometry students with: (1) preferred geographical location of practice, specifically preference to work in urban vs. rural areas; and (2) preferred career specialties, specifically interest in primary health care. METHODS Medical, nursing, pharmacy and optometry students completed a questionnaire at graduation that included questions about levels of New Zealand Government Student Loan debt and preferences regarding location of practice and career specialty. In an additional survey, medical students were asked to self-rate the effect of financial factors on their career choices. RESULTS Debt patterns varied across programmes. Medical and pharmacy students with high debt were significantly more likely than students with low debt to prefer rural over urban practice (P = 0.003). There was no difference in level of interest in a primary care specialty by debt level for any programme. Medical students reported little influence of debt on career choice, although students with high debt levels were less concerned over career financial prospects than students with lower levels of debt. DISCUSSION Current levels of student debt do not deter students from planning a career in rural or primary care settings. Somewhat surprisingly, higher levels of debt are associated with greater rural practice intentions for medical and pharmacy students, although the underlying reasons are uncertain.

To which countries do European psychiatric trainees want to move to and why?

BACKGROUND: There is a shortage of psychiatrists worldwide. Within Europe, psychiatric trainees can move between countries, which increases the problem in some countries and alleviates it in others. However, little is known about the reasons psychiatric trainees move to another country. METHODS: Survey of psychiatric trainees in 33 European countries, exploring how frequently psychiatric trainees have migrated or want to migrate, their reasons to stay and leave the country, and the countries where they come from and where they move to. A 61-item self-report questionnaire was developed, covering questions about their demographics, experiences of short-term mobility (from 3 months up to 1 year), experiences of long-term migration (of more than 1 year) and their attitudes towards migration. RESULTS: A total of 2281 psychiatric trainees in Europe participated in the survey, of which 72.0% have 'ever' considered to move to a different country in their future, 53.5% were considering it 'now', at the time of the survey, and 13.3% had already moved country. For these immigrant trainees, academic was the main reason they gave to move from their country of origin. For all trainees, the overall main reason for which they would leave was financial (34.4%), especially in those with lower (<500€) incomes (58.1%), whereas in those with higher (>2500€) incomes, personal reasons were paramount (44.5%). CONCLUSIONS: A high number of psychiatric trainees considered moving to another country, and their motivation largely reflects the substantial salary differences. These findings suggest tackling financial conditions and academic opportunities.

Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States.

Importance: Hospital-employed physicians provide primary care within the hospital or within community-based office practices. Yet, little is understood regarding the influence of hospital location and ownership on the delivery of low-value care. Objective: To assess the association of hospital location and hospital ownership with the provision of low-value health services. Design, Setting, and Participants: This study compared low-value service use after primary care visits at hospital-based outpatient practices from January 1, 1997, to December 31, 2011, vs community-based office practices and at hospital-owned vs physician-owned community-based office practices from January 1, 1997, to December 31, 2013. Logistic regression models adjusted for patient and health care professional characteristics and year, and weighted results were used to reflect population estimates. Results were also stratified by symptom acuity and whether a generalist physician (eg, general internist or family practitioner) was the patient's primary care provider. This study used nationally representative data from the National Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2013) and the National Hospital Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2011) on outpatient visits to generalist physicians. Participants were patients seen with 3 common primary care conditions, namely, upper respiratory tract infection, back pain, and headache. Main Outcomes and Measures: The use of antibiotics (for upper respiratory tract infection), computed tomography or magnetic resonance imaging (for back pain and headache), radiographs (for upper respiratory tract infection and back pain), and specialty referrals (for all 3 conditions). Results: This study identified 31 162 visits for upper respiratory tract infection, back pain, and headache, representing an estimated 739 million US primary care visits from 1997 to 2013. Compared with visits with community-based physicians, patients in visits to hospital-based physicians were younger (mean age, 44.5 vs 49.1 years; P < .001) and less frequently saw their primary care provider (52.7% vs 81.9%, P < .001). Although antibiotic use was similar in both settings, hospital-based visits had more orders for computed tomography and magnetic resonance imaging (8.3% vs 6.3%, P = .01), radiographs (12.8% vs 9.9%, P < .001), and specialty referrals (19.0% vs 7.6%, P < .001) than community-based visits. Multivariable adjustment and symptom acuity stratification revealed similar findings. Visits with a generalist other than the patient's primary care provider were associated with greater provision of low-value care but mainly within hospital-based settings. Practice patterns were similar among hospital-owned vs physician-owned community-based practices with the exception of specialty referrals, which were more frequent in hospital-owned community-based practices. Conclusions and Relevance: Visits to US hospital-based practices are associated with greater use of low-value computed tomography and magnetic resonance imaging, radiographs, and specialty referrals than visits to community-based practices, and visits to hospital-owned community-based practices had more specialty referrals than visits to physician-owned community-based practices. These findings raise concerns about the provision of low-value care at hospital-associated primary care practices.

Opinion and Special Articles: Loan forgiveness options for young neurologists: Current landscape and practice implications.

Increasing education debt has led to the availability of a variety of loan forgiveness options including the Department of Education's Public Service Loan Forgiveness (PSLF) program. This article discusses the current landscape of loan forgiveness options including trends in PSLF for rising neurology trainees, and implications for choices in specialization, employment, practice location, and the pursuit of an academic career. We further provide guidance on how to navigate the various loan forgiveness options that neurology residents and fellows may consider.

Geographic and Age-Based Variations in Medicare Reimbursement Among ASSH Members.

Background: The purpose of this study was to investigate how American Society for Surgery of the Hand (ASSH) members' Medicare reimbursement depends on their geographical location and number of years in practice. Methods: Demographic data for surgeons who were active members of the ASSH in 2012 were obtained using information publicly available through the US Centers for Medicare and Medicaid Services (CMS). "Hand-surgeons-per-capita" and average reimbursement per surgeon were calculated for each state. Regression analysis was performed to determine a relationship between (1) each state's average reimbursement versus the number of ASSH members in that state, (2) average reimbursement versus number of hand surgeons per capita, and (3) total reimbursement from Medicare versus number of years in practice. Analysis of variance (ANOVA) was used to detect a difference in reimbursement based on categorical range of years as an ASSH member. Results: A total of 1667 ASSH members satisfied inclusion in this study. Although there was significant variation among states' average reimbursement, reimbursement was not significantly correlated with the state's hand surgeons per capita or total number of hand surgeons in that given state. Correlation between years as an ASSH member and average reimbursement was significant but non-linear; the highest reimbursements were seen in surgeons who had been ASSH members from 8 to 20 years. Conclusions: Peak reimbursement from Medicare for ASSH members appears to be related to the time of surgeons' peak operative volume, rather than any age-based bias for or against treating Medicare beneficiaries. In addition, though geographic variation in reimbursement does exist, this does not appear to correlate with density or availability of hand surgeons.

New York State Dental Establishments and Dentists: 2007-2012. Economic Survey.

Every five years a series of studies is carried out by the Census Bureau which provides an opportunity to review the basic economic well-being of the many industries at the national, state and county levels. A comparison of dental economic data from the 2007 and 2012 studies for the period that encompassed the 2007-2009 "Great Recession" details the general economic difficulties faced by the dental profession during this period.

Variations in Medicare Reimbursement in Radiation Oncology: An Analysis of the Medicare Provider Utilization and Payment Data Set.

PURPOSE: The purposes of this study were to summarize recently published data on Medicare reimbursement to individual radiation oncologists and to identify the causes of variation in Medicare reimbursement in radiation oncology. METHODS AND MATERIALS: The Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (POSPUF), which details nearly all services provided by radiation oncologists in 2012, was used for this study. The data were filtered and analyzed by physician and by billing code. Statistical analysis was performed to identify differences in reimbursements based on sex, rurality, billing of technical services, or location in a certificate of need (CON) state. RESULTS: There were 4135 radiation oncologists who received a total of $1,499,625,803 in payments from Medicare in 2012. Seventy-five percent of radiation oncologists were male. The median reimbursement was $146,453. The code with the highest total reimbursement was 77418 (radiation treatment delivery intensity modulated radiation therapy [IMRT]). The most commonly billed evaluation and management (E/M) code for new visits was 99205 (49%). The most commonly billed E/M code for established visits was 99213 (54%). Forty percent of providers billed none of their new office visits using 99205 (the highest E/M billing code), whereas 34% of providers billed all of their new office visits using 99205. For the 1510 radiation oncologists (37%) who billed technical services, median Medicare reimbursement was $606,008, compared with $93,921 for all other radiation oncologists (P<.001). On multivariate analysis, technical services billing (P<.001), male sex (P<.001), and rural location (P=.007) were predictive of higher Medicare reimbursement. CONCLUSIONS: The billing of technical services, with their high capital and labor overhead requirements, limits any comparison in reimbursement between individual radiation oncologists or between radiation oncologists and other specialists. Male sex and rural practice location are independent predictors of higher total Medicare reimbursements.

Regional differences of outpatient physician supply as a theoretical economic and empirical generalized linear model.

BACKGROUND: Regional differences in physician supply can be found in many health care systems, regardless of their organizational and financial structure. A theoretical model is developed for the physicians' decision on office allocation, covering demand-side factors and a consumption time function. METHODS: To test the propositions following the theoretical model, generalized linear models were estimated to explain differences in 412 German districts. Various factors found in the literature were included to control for physicians' regional preferences. RESULTS: Evidence in favor of the first three propositions of the theoretical model could be found. Specialists show a stronger association to higher populated districts than GPs. Although indicators for regional preferences are significantly correlated with physician density, their coefficients are not as high as population density. CONCLUSIONS: If regional disparities should be addressed by political actions, the focus should be to counteract those parameters representing physicians' preferences in over- and undersupplied regions.

A Comparison of the J-1 Visa Waiver and Loan Repayment Programs in the Recruitment and Retention of Physicians in Rural Nebraska.

PURPOSE: There is a dearth of literature evaluating the effectiveness of programs aimed at recruiting and retaining physicians in rural Nebraska. Taking advantage of the Nebraska Health Professional Tracking System, this study attempts to comparatively assess the effectiveness of the J-1 visa waiver and state loan repayment programs in the recruitment and retention of physicians in rural Nebraska. METHODS: A mixed methods approach was used. We tracked 240 physicians who enrolled in the J-1 visa waiver and state loan repayment programs between 1996 and 2012 until 2013. In addition, key informant interviews were conducted to obtain perspectives on the recruitment and retention of physicians in rural Nebraska through the 2 programs. FINDINGS: Results from multilevel survival regression analysis indicated that physicians enrolled in the J-1 visa waiver program were more likely to leave rural Nebraska when compared with those enrolled in the state loan repayment program. Participants in the qualitative study, however, cautioned against declaring one program as superior over the other, given that the 2 programs addressed different needs for different communities. In addition, results suggested that fostering the integration of physicians and their families into rural communities might be a way of enhancing retention, regardless of program. CONCLUSION: The findings from this study highlight the complexity of recruitment and retention issues in rural Nebraska and suggest the need for more holistic and family-centered approaches to addressing these issues.

The economic contribution of the Northern Ontario School of Medicine to communities participating in distributed medical education.

INTRODUCTION: The economic contribution of medical schools to major urban centres can be substantial, but there is little information on the contribution to the economy of participating communities made by schools that provide education and training away from major cities and academic health science centres. We sought to assess the economic contribution of the Northern Ontario School of Medicine (NOSM) to northern Ontario communities participating in NOSM's distributed medical education programs. METHODS: We developed a local economic model and used actual expenditures from 2007/08 to assess the economic contribution of NOSM to communities in northern Ontario. We also estimated the economic contribution of medical students or residents participating in different programs in communities away from the university campuses. To explore broader economic effects, we conducted semistructured interviews with leaders in education, health care and politics in northern Ontario. RESULTS: The total economic contribution to northern Ontario was $67.1 million based on $36.3 million in spending by NOSM and $1.0 million spent by students. Economic contributions were greatest in the university campus cities of Thunder Bay ($26.7 million) and Sudbury ($30.4 million), and $0.8-$1.2 million accrued to the next 3 largest population centres. Communities might realize an economic contribution of $7300-$103 900 per pair of medical learners per placement. Several of the 59 interviewees remarked that the dollar amount could be small to moderate but had broader economic implications. CONCLUSION: Distributed medical education at the NOSM resulted in a substantial economic contribution to participating communities.

INTRODUCTION: Les écoles de médecine peuvent apporter des avantages économiques importants aux grands centres urbains. On n'en sait guère toutefois sur l'apport économique, pour les communautés participantes, des écoles qui offrent des cours et de la formation hors des grandes villes et loin des centres universitaires des sciences de la santé. Nous avons voulu évaluer la contribution économique de l'École de médecine du Nord de l'Ontario (EMNO) aux communautés qui participent à ses programmes d'apprentissage distribué. MÉTHODES: Nous avons créé un modèle économique local et utilisé les dépenses réelles de 2007/08 pour évaluer l'apport économique de l'EMNO aux communautés du Nord de l'Ontario. Nous avons aussi estimé l'apport économique des étudiants en médecine ou des médecins résidents qui participent aux divers programmes offerts dans les communautés éloignées des campus de l'université. Enfin, pour explorer les répercussions économiques plus vastes, nous avons effectué des entrevues semi-structurées auprès de chefs de file des milieux de l'éducation, des soins de santé et de la politique dans le Nord de l'Ontario. RÉSULTATS: L'apport économique total de l'EMNO s'est chiffré à 67,1 millions de dollars (dépenses de l'École, 36,3 millions; dépenses des étudiants, 1,0 million). L'apport économique a été le plus important pour les villes qui hébergent un campus de l'université, soit Thunder Bay (26,7 millions) et Sudbury (30,4 millions), les 3 centres suivants en importance bénéficiant d'un apport de 0,8 à 1,2 million de dollars. Les communautés peuvent réaliser des bénéfices économiques de 7 300 $ à 103 900 $ par paire d'apprenants en médecine par placement. Plusieurs des 59 personnes interviewées ont souligné que le montant des contributions, en argent, peut être assez petit ou moyen, mais que les répercussions économiques se font sentir à plus grande échelle. CONCLUSION: L'éducation médicale distribuée à l'EMNO a apporté une contribution économique substantielle aux communautés participantes.