San Francisco, CA—Although the field of rheumatology is thriving, with strong professional associations, advances in science and technology, and a large and expanding market, the players in the field have been dwindling, according to Paul H. Caldron, DO, PhD, FACP, FACR, MBA, Managing Member, Clinical Scientist, Arizona Arthritis & Rheumatology Associates, who discussed the state of rheumatology at the Coalition of State Rheumatology Organizations (CSRO) 2019 Fellows Conference.
“The projections are that, due to attrition and the rate at which our training programs can produce new rheumatologists, we’re not looking so good. There’s going to be a decline,” Dr Caldron told attendees. “Overall, there is going to be a 31% decrease in manpower, commensurate with a 138% increase in demand by 2030.”
This translates to a manpower deficit of 700 rheumatologists relative to current demand, and by 2030, a deficit of 4100 rheumatologists. The prediction, gleaned from the American College of Rheumatology (ACR) 2015 Workforce Study1 has been years in the making. The ACR 2005-2006 Workforce Study predicted a discrepancy of nearly 45% between the increase in rheumatologists and the demand for their services.
Understanding the Manpower Deficit
Choosing rheumatology as a career path comes with perks, including intellectual stimulation, respect from colleagues, few patient emergencies, long-term relationships with patients, exciting new therapies, and a substantial income. The income is relative, however, when one examines the annual salaries of physicians in other medical specialties.
“You could look at any survey of physician incomes and see that rheumatology tends to ride toward the bottom third, the bottom quarter, without much more return on your investment for the 2 years you spent past internal medicine,” Dr Caldron said, referring to a 2018 salary survey2 in which rheumatologists’ annual compensation ranked 22nd among 29 specialties, at $257,000.
Efforts are being made to attract greater numbers of students to the specialty and, to some extent, these efforts have been successful. In 2012, 100 rheumatology fellowship programs attracted 240 applicants for 187 available positions. By 2018, those numbers had swelled to 113 programs, 313 applicants, and 221 available positions.
Nonetheless, factors working against the rheumatology workforce are significant. A concept called opportunity cost is one of these factors. Defined as the loss of potential gain when one opportunity is chosen over another, opportunity cost could contribute to rheumatologists’ decreasing numbers, according to Dr Caldron.
Another factor in the waning workforce is a predicted 50% retirement rate over the next 15 years. International medical graduates (IMGs) also play a role. In 2016, IMGs comprised 60% of rheumatology fellows, and approximately 17% of these individuals left the United States after their education was complete.
There are increasing numbers of women entering the specialty, and these individuals are estimated to represent 59% of rheumatologists by 2030.
“Why is this important? Because women have better things to do with their lives,” Dr Caldron said. “They have children, they raise families, they organize families, they organize our lives, and they tend, statistically, to spend fewer years in practice and fewer hours a week in practice.”
Millennial ascendancy is giving rise to a dynamic similar to that of the gender shift. In general, persons within the millennial age bracket want a better life for themselves compared with those of their predecessors.
“They want a better work-life balance,” Dr Caldron said. “They’re expected to maybe work half-time or part-time instead of full-time.”
Factoring in the changing rheumatology workforce with the ACR 2015 Workforce Study reveals that approximately 107 full-time equivalents will graduate annually and enter the field as rheumatologists in the coming years—a number that will not keep up with the expected attrition rate.
Optimizing Private Practice
Rheumatologists in private practice are taking action to change this dynamic, with the belief that the greatest risk to the quality of care for a patient with rheumatic disease is the unavailability of a rheumatologist, a guiding principle of the ACR. To optimize profitability, thereby being able to compete for young physicians and meet the United States demand, rheumatologists in private practice must optimize their business practices, Dr Caldron noted.
United Rheumatology and McKesson Specialty Network are 2 organizations that can help with this, offering an array of services rheumatologists can purchase to help their businesses run better. American Arthritis and Rheumatology Associates is a multistate group across 20 states, partially owned by a management company that operates under a single tax ID.
Arizona Arthritis & Rheumatology Associates, of which Dr Caldron was a Founder, has practicing rheumatologists as all of its shareholders. It operates in integrated business units, with teams of physicians and advance practice clinicians (APCs), along with ancillary services in their own functioning business units. Similar to this group is Articularis Healthcare, a rheumatology organization with locations across Georgia and South Carolina, which is also fully owned by practicing rheumatologists and operates under a single tax ID.
“So, there have been some efforts, and we hope to see these grow and succeed,” Dr Caldron noted.
The Bargaining Power of Buyers
Among the forces governing the rheumatology industry, the one posing the greatest difficulty is the bargaining power of buyers. The major healthcare buyers under the umbrella of government, through Medicare, Medicaid, the military, and the Veterans Administration, have a great deal of bargaining power.
“They wrap their arms around a huge section of the population, and they set a fee schedule, and if you want to have access to those patients, you have to adopt the fee schedule,” Dr Caldron said.
Managed care represents the other side of the coin, offering insurance coverage to the employees of large companies at a lower rate to the employer. Managed care plans are able to do this using the same model the government uses—by setting a fee schedule to which doctors and hospitals must adhere if they want access to patients.
“The analysts would look at this and say, in the bigger view, the law of supply and demand isn’t working; there are distortions going on,” Dr Caldron said, adding that rheumatologists in practice during the 1990s found their incomes remaining flat despite seeing more and more patients.
Operational considerations—things that go on inside and outside the walls of one’s practice that affect success—must also be taken into account. Internal marketing involves educating staff about the promise on which a practice plans to deliver care to patients, so that they can help to deliver it more effectively. In addition, Dr Caldron stressed the importance of well-paid, highly trained staff who truly understand what rheumatology is about.
“If you do it well, that will support you and make your life that much more enjoyable,” he said.
In the external environment, one major operational consideration is adding services. Dr Caldron pointed out that approximately 20% of the healthcare dollar goes into the rheumatologist’s pocket for their cognitive services.
“Your pen drives that other $.80. It would traditionally drive it outside of your office for labs, imaging, and all kinds of other services. If you’re in an industry where the players are receding in the face of a huge market, it behooves you to try to drive that cash flow inside your walls rather than outside your walls,” he said.
Solutions to Increase the Rheumatology Workforce
Summing up solutions to the burgeoning manpower problem in rheumatology, Dr Caldron emphasized the importance of reducing opportunity cost by better managing practices, expanding training capacity—particularly expanding program availability in underserved areas—and lowering the load of certain patient groups in practices.
“We need to move out of our practices the osteoarthritis, the fibromyalgia—the things that other people can do probably as well as we can, so we can concentrate on other rheumatic diseases,” he said.
In addition, there must be a push for loan repayment plans for graduating rheumatologists, as they pay as much for their education as physicians in higher-income specialties. Immigration reform is also needed, with a possible solution being the requirement of a green card for acceptance to rheumatology fellowships, Dr Caldron said. Along with expanded efforts in education, young rheumatologists should be helped along with mentoring, both to teach them business acumen and to instill in them a feeling of ownership, he added.
Bringing in more APCs is another way to help fill the rheumatologist gap. Although barriers exist, including the lack of rheumatology fellowships for APCs and the time required to train these individuals, it is a worthwhile endeavor.
“It typically pays off very well,” he said, adding, “This could be a lifeline to us.”
- Bolster MB, Bass AR, Hausmann JS, et al. 2015 American College of Rheumatology Workforce Study: the role of graduate medical education in adult rheumatology. Arthritis Rheumatol. 2018;70:817-825.
- Kane L. Medscape physician compensation report 2018. April 11, 2018. www.medscape.com/slideshow/2018-compensation-overview-6009667. Accessed September 23, 2019.