♪♪♪ Iowa has a shortage of physicians, especially in rural areas.

We'll discuss how to address that challenge and other health care issues on this edition of Iowa Press.

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♪♪♪ For decades, Iowa Press has brought you political leaders and newsmakers from across Iowa and beyond.

Celebrating more than 50 years on statewide Iowa PBS, this is the Friday, September 13th edition of Iowa Press.

Here is Kay Henderson.

♪♪♪ Henderson: A couple of years ago, a hospital in Southeast Iowa closed.

At the end of this month, a hospital in Northwest Iowa is closing.

And last month, it was announced that a hospital in Central Iowa will be closing its labor and delivery department.

Those are some of the issues that we will bring up with our group of guests on this edition of Iowa Press.

They are health care professionals.

Let me introduce them.

First, we have Dr. Christina Taylor.

She is the Chief Medical Officer of Clover Health, it's a value-based care division, and President of the Iowa Medical Society Board of Directors.

Next, we have Dr. Gerard Clancy.

He is Senior Associate Dean of External Affairs and Clinical Professor of Psychiatry and Emergency Medicine at the University of Iowa's Carver College of Medicine.

Also joining us is Steve Churchill.

He is a former state legislator, a former aide to Governor Terry Branstad when he was Ambassador to China, and he is currently the CEO of the Medical Society.

To you three, welcome and thanks for being here.

Thank you for having us.

Henderson: Joining our conversation, Stephen Gruber-Miller of the Des Moines Register and Erin Murphy of the Gazette in Cedar Rapids.

Murphy: So, Kay mentioned the hospital closures in Keokuk and Primghar.

Dr. Taylor, let me start with you on this.

Is that a worrying issue as far as is there more to come?

Is this a trend?

Or how can we avoid future closures like that, especially in our rural areas?

Taylor: Well, thanks for asking.

This is one of the main reasons that we're here today is we want to discuss the looming crisis of health care workforce shortage in the state of Iowa.

We actually have a very looming physician shortage and it is a real issue and we're concerned about the ability to maintain proper access for Iowans.

Murphy: So, how do we avoid that?

How do we avoid this from happening again in other rural areas of the state?

Taylor: Sure, well there's a variety of things, it's a multi-factorial issue.

There's lots of reasons why we have a workforce shortage.

And we can get into a lot of the specifics of what are the specific things contributing to why don't we have enough providers in the state.

Actually, Iowa ranks 45th out of the states in terms of the patient to physician ratio.

And we're at a critically low level of physicians.

We have, as of recent data, we have about 5,778 doctors down from just 5,900 a single year ago.

So, we are seeing the number of practicing physicians in the state decrease.

And so, we're here today as the Iowa Medical Society to discuss not only the situation at hand, but then to bring forth hopefully several solutions for that.

Murphy: Dr. Clancy, you see the same issue?

Clancy: I do.

It's a complex issue.

We have a terrible mismatch of demand for health care versus the supply of all of our health care workers, including the physicians.

10,000 baby boomers are retiring every day in America right now.

Those baby boomers need more health care and at the same time we have not caught up on the number of physicians to be able to match that demand for health care.

Murphy: And Steve, Kay also mentioned the Newton Hospital ending their labor delivery, which relates to specifically within this broader context a shortage of OBGYN physicians.

Describe for us the lay of the land there.

Churchill: Well, I read about that as well.

It's a challenge for OBGYN.

But also, any time you have one specialty physician missing from a practice, and so if you have a missing radiologist or any critical part of that health care chain, it has a real impact.

And I think that is what we saw happening in Newton.

Certainly there has been a challenge in Iowa to recruit and retain OBGYN physicians for a period of time.

And I think that is partially because of our rural status, but I think there's a lot of other factors as well.

But that is why the Iowa Medical Society is working as a convener to bring together physician leaders, hospital leaders, people from across the state to identify solutions.

The AMA predicts that within the next ten years there will be a shortage of 124,000 physicians.

When you think about that, that's not someone you can just turn out overnight.

There's four years of undergraduate school, four years of medical school and a minimum of three years and up to seven years of residency training.

So, you can't just change that at the flip of a switch.

And so, as we had mentioned, our vision is to make Iowa the premier destination for physicians to live, work and to serve their communities.

And we've identified five core areas where we think Iowa can make a difference so that we are a leading authority.

And one of those core areas focuses on residency slots for our medical students being matched.

And I think probably Dr. Clancy could speak more to that.

But that is the leading indicator of where a medical student, a resident will choose to practice is where they went to residency school, a residency slot, in Iowa we have a shortage.

Gruber-Miller: Dr. Clancy, we're talking about the OBGYN shortage, I want to put a little finer point on it.

One of the factors we hear about and might be affecting this, is the state's new abortion law, which bans the procedure after about six weeks of pregnancy.

How is that affecting maybe recruitment and sort of retention of students and just the OBGYN program at Iowa?

Clancy: It's early right now so we'll have to see.

It certainly is a concern and something we'll have to watch.

But so far the OBGYN residency program is one of the finest in the country.

So, we're very proud of it.

Gruber-Miller: Yeah, and Dr. Taylor, I'm curious, on other states with similar abortion laws we see doctors and hospitals struggling with when to apply the law's exceptions, particularly for the life of the mother.

How do doctors in Iowa go about making those decisions?

And is there any kind of concern that they might run afoul of licensing discipline if they make the wrong call?

Taylor: Well, this is one reason that as the Iowa Medical Society, we oppose measures that interfere with the sanctity of the patient-physician relationship.

The care of an individual patient needs to remain truly in the care location between the doctor and the patient at the time of care.

And so, yes, I think there is real concern from physicians around the state of how do they address patient care because there's gray zones right now and we haven't, those haven't played out yet.

So that is a real issue of ours.

Gruber-Miller: What is the process like if this were to happen, if there were a patient with a health issue who might need an abortion for their, to save their life or avoid a major medical complication?

Taylor: I think it would highly depend on -- it's hard for me to comment because I think it would highly depend on the variables of the circumstance.

But the law is very clear about elective abortion right now.

But in terms of the life of the mother, the exceptions clause is very gray.

And when you have someone in an emergent situation, you don't necessarily, people do worry about their licensure.

It is a real concern.

How do you weigh how sick someone is and is this a true emergency?

Is this not?

And you can sometimes wait until it's too late.

And so, there is a real fear of that happening.

But this is something that will play out and we will have to find out where those gray zones are and we'll have to work together as a state towards solutions.

The one thing that we're here to address today is to say how can we increase the number of providers, just have access to care?

And that is one thing that we are agreed on is regardless of how you see this particular issue, and that is increasing the number of physicians in the state.

And so, we are truly focusing right now on can we have enough physicians in the state to provide care?

Churchill: And the physician shortage crisis, and it is a crisis, is a single issue that is not divided by rural or urban or republican or democrat.

It has universal support.

And we made a big step last year with medical malpractice Tort reform that makes Iowa a better place to recruit physicians to live.

And today we want to talk about other things that we can do that will help us to move from 45th to a better position in terms of the number of patient-physician ratio.

Henderson: Dr. Clancy, you are in the realm of, I guess your background is in the realm of mental health.

Clancy: Yes.

Henderson: The legislature has passed a redesign of the system for providing mental health services in Iowa.

In your view, how will that affect patient care?

Clancy: The layers of mental health services that we offer across the state are really struggling right now.

Again, back to the shortages of clinicians, the redesign and the regionalization is probably a very good thing as far as being able to have a common set of practices for everybody across the regions.

But at the heart of it is still the clinician shortage that we have right now.

We just do not have enough of the mental health providers, not enough psychiatrists, not enough social workers as well.

Henderson: The legislature has provided money for slots at your institution, your educational institution.

How many more do you need?

Clancy: You know, the legislature essentially allowed us to double our residency program in psychiatry and we're very hopeful that that will be at least a major contributor to the psychiatrist supply.

But we're short on nurses as well.

We're short on physician assistants.

We're short on nurse practitioners as well.

So, it really takes a comprehensive look at what we need as far as the mental health workforce.

Henderson: Dr. Taylor, is it just finding more slots?

Or is it also changing the licensing process to get different, people with different skill sets providing this care at different levels?

Taylor: You know, so I think you're getting to this being a multi-factorial approach to the problem.

So yes, we need more residency slots without a doubt.

And if we increase the number of residency programs in the state, we will increase the number of people who practice here.

It's the number one factor of where people choose to practice is where did I train.

You go there, you train there, you stay.

Churchill: Our goal is increase resident slots by 200, which would be significant and really have an impact on the number of physicians practicing in the state.

Henderson: Would those exclusively be at the University of Iowa?

Or would they also be at Des Moines University?

Taylor: So, residency programs are at your major health care centers.

So, you have to have a nidus of enough patients, of enough variety for that specialty in order for that specialty to be trained.

So, we have residency, several residency programs in Des Moines and Cedar Rapids and Sioux City and we have family practice programs dotted around the state and others as well.

So, they don't all have to be at the medical school center.

Henderson: What about the role of physician's assistants?

Steve Churchill?

Churchill: They play a critically important role.

Henderson: Would that be an easier way to help rural Iowa, to have more physician's assistants?

Churchill: Well, physician assistants work closely with physicians.

And, as Dr. Taylor said, it's a multi-faceted approach.

It's a team that is working together with the nurse practitioners and others.

So, they are an important part of the team.

But we do believe that the physician is an essential element of that team in terms of working together to make sure that there is the best care for the physician.

So, we support physician's assistants.

We want to work with them.

We want to make sure that the physician is a key decision maker in that patient consultation.

Murphy: Go ahead, Doctor.

Taylor: I was just going to say, I would add to that.

It is very much team-based care.

We have moved from just one doctor and one patient to it takes a team to manage all of a patient's care and provide all of the services that person needs.

You have nurses.

If you have a patient with a lot of chronic illnesses then usually you have a care manager as well.

So, you have nurses and you have doctors and you may have, as your primary care provider you may have a nurse practitioner or physician's assistant.

In a rural state where we have access to care issues, we need as many health care providers as we can get.

And then we need to work in a coordinated fashion and make sure that we have good oversight of physicians able to make ultimate decisions in patient care and in management.

But we need all those members of the health care workforce.

Murphy: I wanted to go back real quick to the residencies because it sounds like that is a big part of what you all feel would be a solution here.

Dr. Clancy, I assume it's not -- for folks who may not be familiar with this, it's not as simple as snapping your fingers and saying, more residency programs.

So, what do we need to make that happen?

Clancy: The residency programs have to fit under the national accreditation standards.

And to do so is a multiyear process just to get residency positions approved to do so.

We're going through that right now for the psychiatry residency positions that were approved by the legislature.

And again, very helpful, but it's a multiyear process to get those programs up and running or up and expanded as well.

So, it's not that easy.

Murphy: And do they require funding of any sort?

Clancy: They do require funding as well.

It's about $100,000 per resident per year to be able to expand that.

Churchill: A lot of those funding channels are in place.

This is something that both the University of Iowa and Des Moines University are completely committed to.

But it's also something that we're working with the health systems that are a part of it.

So, there's a lot of people that need to come together to make it happen.

But everyone agrees that if we increase residency slots, we will increase the number of practicing physicians in Iowa and we are taking the lead to ensure that that happens over the course of the next several years.

Murphy: I wanted to also pick your folks' brains and get your expertise on something that Iowans are talking about and that is the high cancer rates in this state.

Dr. Taylor, I'll start with you.

Big picture view, Iowa has a higher cancer rate than many other states, many neighboring states.

Do we know why?

And what in your view would you like to see happen that would help address that?

Taylor: Right, and I'll turn to Dr. Clancy to add in here as well because you do a lot of this work at the University of Iowa.

But I hate to keep using the word multi-factorial, but it truly is.

There's a lot of things that play a role, genetics.

Thankfully we actually are living longer, so we are living longer and finding more cancer.

Generations ago people died of heart attacks and strokes a lot younger and they didn't live long enough to find the cancer.

So, there's a little bit of that and we're an older state.

Unfortunately, our tobacco use is too high.

So that plays a giant role, as do some of our lifestyle choices.

And then there may be other factors as well.

There's a lot of theories.

But we haven't been able to nail down precise culprits.

Churchill: The AMA did a recent study that really talked about access to care.

And because we're a rural state and rural communities do not have the access to care as some of the urban areas, I think that is a huge contributor as well is being diagnosed later because they're not having as regular access to see their physician.

Murphy: What else, Dr. Clancy?

Clancy: Unfortunately, during the pandemic, as you would expect, we were all told to stay home.

And so, individuals stayed home as far as their screenings as well.

And nationally we've had a big drop in colon screenings, breast screenings, cervical screenings and the result of that has been unfortunately diagnosing much later in the cancer progress for breast cancer, colon cancer and cervical cancer as well.

And maybe that has hit Iowa a little bit harder than other states as well.

We always look at diet.

We always look at alcohol intake as well.

Henderson: But Iowa's cancer incidence is increasing.

So, why is it happening here and not states similarly situated?

There are rural people who live in Nebraska.

There are rural people who live in Wisconsin.

Clancy: Kay, I don't have the details on that one yet.

We know the number, we know it's increasing.

We're trying to figure that out.

Gruber-Miller: I want to ask a little bit about vaccines.

Dr. Clancy, we've seen over the past few years increases in children getting exemptions from the vaccines you need to get before you go to school.

What does that trend tell us?

Is there a concern there that we might reach some kind of issue where there's too many people not getting these childhood vaccinations?

Clancy: Absolutely.

I mean, we've seen viruses that we thought were pretty much put to bed on their way back now.

We're seeing a resurgence of some polio as well.

So yes, we're very concerned about that.

Henderson: And Dr. Taylor, you were on a task force on this very topic.

Taylor: Yes, indeed.

American Medical Group Association had an adult vaccine task force and I've been part of a number of efforts to improve vaccines in both children and adults.

Vaccines remain the single most effective way to prevent and eliminate the diseases that we have the vaccines for.

You think of things like polio.

Polio should not exist anymore.

It should be gone, eradicated.

There are pockets of resurgence of things like measles and you think oh, okay great, somebody gets the measles.

It's devastating for some people.

You might have a child who is sick for a week and then they recover and it's fine.

You have others who end up having lifelong illnesses, organ damage and death.

And these are entirely preventable.

Gruber-Miller: Dr. Taylor, just really briefly, the new COVID vaccines are out this fall.

Talk us through, do we expect many Iowans to be getting these boosters?

And then talk us through why they might want to do that.

Taylor: I can't speak to whether we expect people to be getting them or not.

But we still do recommend them.

Yes, we absolutely do.

Very similar to getting the flu shot, particularly if you are an individual who is at risk for cardiopulmonary disease, if you're someone who you have chronic lung problems or you're immunosuppressed in any way, you're young, you're old, those people are particularly at risk of having both influenza and COVID, of having a more serious illness, the type that ends up in the hospital, on a ventilator, death certainly for people who are extremely vulnerable.

People do still die from these diseases.

And then it's just the getting sick and the debility.

It's the time away from work, it's the time away from school, it's all of those things that you just don't need or want those things either.

Henderson: Dr. Clancy, one reason some doctors choose not to practice in Iowa is because of reimbursement rates.

So, what do policymakers need to do to respond in terms of Medicare, which is reimbursement rates set at the federal level, and Medicaid reimbursement rates, which are set in concert with the state which manages the system?

Clancy: So, an important statistic is that about 400 physicians a year in Iowa stop practicing.

You would think maybe that's to retirement as the lead.

And it's about 35% of those 400 stop practicing for retirement.

But about 44% relocate out of Iowa.

And so, reimbursement and what you can get paid in other states compared to Iowa is a significant factor.

When we see these physicians leave Iowa, often times it is for a better opportunity and sometimes it is for compensation.

So, these are major issues.

How Medicare rates are set are regional and Iowa is unfortunately on the lower end of that regional reimbursements.

Henderson: So, at the Iowa Medical Society, I don't know which one of you wants to swing at this, but how much do you need it to be raised?

25%?

20%?

Steve Churchill, are you going to tell legislators what to do?

Churchill: Well, the AMA's top legislative priorities are the reimbursement rate at the federal level and also prior authorization.

And I can't tell you a number, but I can tell you that we're not only not keeping up with inflation, we're behind.

And so, physicians are really being hurt, particularly in Iowa because rates depend on your population based and the numbers that are focused on that.

So, rural is reimbursed different than urban communities for physicians and rural areas are hurting.

Senator Grassley and Senator Joni Ernst have really focused on that.

But another really big issue that deals with reimbursement is prior authorization.

And when patients are wanting to get certain procedures, they need to get authorization from the health care provider, health insurance providers and that has really become a big issue in terms of burnout for physicians, in terms of the amount of time that the physicians can spend with a patient versus the front office.

So, that administrative burden and the burnout and the prior authorization is really going to be our focus during the next session of the Iowa legislature to try to streamline that so that patients can get their care more quickly.

Henderson: So, are you talking about Medicaid and managed care organizations that are handling that, Dr. Taylor?

Taylor: So, to Steve's point about prior authorization, so that is the process that you have to go through to have a procedure approved with the insurance company, whomever, and it is taking sometimes upwards of one to two hours for a single procedure for the physician or the nurse to spend on the phone to get the authorization for the patient's procedure.

So, we need to streamline that.

We need to absolutely work with the insurance companies.

And we do need help from our legislature on helping us to reform the prior authorization process because it has gotten out of hand.

It was originally started with maybe good intention to understand utilization and maybe prevent tests that weren't needed.

But people are by and large working very hard to keep costs of care down.

Nobody wants a patient in the hospital if they don't need to be in the hospital and the hospitals are full anyway.

So, we have waiting lines to get people in and get things done.

We're not looking to do things we don't need.

So, we absolutely need to reform the prior authorization part because it has added dramatically to the administrative burden of the providers.

And that is one of the reasons why we have difficulty retaining doctors in this state.

Henderson: So, you're saying you want state legislators to do that.

Wouldn't it be better to have a federal standard?

Taylor: It's usually driven by the state.

It would be nice if there was something federal.

Yes, that would be lovely.

But we would probably be able to act quicker in the state than in the federal.

Churchill: It's pretty tough to get things done on the federal level, period.

It's almost impossible And the AMA is working on that.

But we want Iowa to be the leader to separate us from other states that actually helps to attract people here because we have a better process.

Henderson: Well, I have to lead us out of this conversation because we're out of time.

Thanks to the three of you for being here.

You can watch every episode of Iowa Press at iowapbs.org.

For everyone here at Iowa PBS, thanks for watching today.

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