Chapter 2.  The Pediatric Rheumatology Workforce:  Current Supply

Current Supply of Pediatric Rheumatologists:  Numbers

In the United States, pediatric rheumatology is among the smallest of the clinical pediatric medical subspecialties (Table 1).  The American Board of Pediatrics (ABP) first offered a certifying exam in pediatric rheumatology in 1992; as of December 2002, the Board has certified 192 pediatric rheumatologists. 

Table 1:  Number of Board Certified Physicians by Pediatric Subspecialty

1 Source:  American Board of Pediatrics available at http://www.abp.org/STATS/WRKFRC/Menu1.htm
² Source: 2003 American Board of Pediatrics Diplomate File

Not all pediatric rheumatologists certify, however.  Data from the 2004 American College of Rheumatology (ACR) Membership Directory reveal that 185 non-trainee physicians in the U.S. identified themselves as pediatric rheumatologists (i.e., Board-certified and non Board-certified) or reported being Board-certified in pediatric rheumatology.  In addition, there were 25 pediatric rheumatology trainee members of the ACR.  ACR and ABP data sources are described in Appendix C.

[D]

Distribution of Pediatric Rheumatologists

 While access to pediatric rheumatology care may be constrained for a variety of reasons, the most conspicuous reason for decreased access is the small number of these providers and their uneven distribution. ^{4, 11}  Past studies have shown that the overwhelming majority of pediatric rheumatologists practice in academic rheumatology settings; ^{6, 12} and nearly all pediatric rheumatologists practice in metropolitan areas. ¹¹  Based on 2004 ACR data, approximately 3 percent of counties in the United States currently have one or more pediatric rheumatologists involved in patient care (Figure 1) and 13 States have none at all: Alabama, Alaska, Arizona, Idaho, Maine, Montana, Nevada, New Hampshire, North Dakota, South Carolina, South Dakota, West Virginia, and Wyoming. ⁶

Table 2: Percent of Pediatric Population Living Within Selected Distances of Board Certified Pediatric Subspecialists, American Board of Pediatrics

The current distribution of pediatric rheumatologists creates a situation in which a substantial portion of the under-18 population in the United States lives more than 50 miles from a provider (Table 2).  Thirty-five percent of the pediatric population in the United States lives more than 50 miles from the nearest pediatric rheumatologist; ¹¹ approximately 18 percent live 100 or more miles from such a provider.  In contrast, less than 10 percent of the pediatric population lives 100 or more miles from a provider for 11 of 16 pediatric subspecialties studied.  The average population-weighted distance between a county in the United States and a pediatric rheumatology provider is 57.9 miles, making it one of the least geographically accessible of the pediatric subspecialties (Table 3).

Table 3:  Average Population-Weighted Distance to the Nearest Provider by Pediatric Specialty

In Figure 2, a Lorenz curve is used to depict the equality of the distribution of pediatric rheumatologists versus the distribution of the under-18 population in the United States.  Over 70 percent of the pediatric population lives within a county that lacks a pediatric rheumatologist; approximately 60 percent of rheumatologists are located in counties where only 10 percent of the pediatric population lives.  Based on the area between the 45-degree line and the Lorenz curve, the Gini coefficient is used to quantify inequality and ranges from 0 (in cases of perfectly even distribution) to 1 (in cases of perfect inequality).  For pediatric rheumatologists in the United States, the Gini coefficient equals .84, suggesting a very inequitable distribution.

Figure 2:  Cumulative Distribution of Pediatric Rheumatologists in United States Counties Weighted by the Population Under-18 Years of Age

[D]

Population

It is important to consider the ratio of pediatric rheumatologists to the under-18 population at a market level.  Because of the low incidence rates of pediatric rheumatic diseases and the geographic concentration of providers, the relevant market for a pediatric subspecialist is likely quite large.  Using the Metropolitan Statistical Areas (MSAs) as a proxy for a market, the relative supply of pediatric rheumatologists was compared to the relative supply of other pediatric subspecialists.  These ratios use “head counts” of providers rather than counts that adjust for percent time involved in patient care because individual level data on percent time in patient care do not exist for all providers.  Furthermore, the percent of time an individual spends in other professional activities likely varies with supply.  That is, providers at institutions with more pediatric rheumatologists may spend more time in research than those in institutions with a single pediatric rheumatologist.  Thus, a single adjustment (i.e., considering every rheumatologist to be involved in patient care at 0.6 FTE) is inappropriate and will not change the relative differences across MSAs.

Only 23 percent of MSAs in the United States have a pediatric rheumatologist available (Table 4).  For all rural (i.e., non-metropolitan) areas, the number of pediatric rheumatologists per 100,000 children under 18 years of age is 0.01.  For all MSAs there is one pediatric rheumatologist per 100,000 children on average.  In the 40 most-populated MSAs, there is one pediatric rheumatologist per 233,000 children on average.  The ratio varies widely in these most populated MSAs from 0.09 per 100,000 children under 18 in Riverside-San Bernardino, California to 1.62 per 100,000 children under 18 in Cincinnati, Ohio.

Table 4:  Ratio of Board Certified Physicians to Under-18 Population (in 100,000) by Pediatric Subspecialty

Source: 2003 ABP Diplomate File

MSA:  Metropolitan Statistical Area

Across all pediatric subspecialties, pediatric rheumatology has the lowest ratio in non-MSAs, the third lowest ratio for all MSAs, and the second lowest ratio in the 40 most populous MSAs.  Some of the differences in supply across specialists reflect, in part, differences in the incidence of diseases treated by these various providers.  The relevant market area may differ across large and small pediatric specialties, too.

Pediatric Rheumatologists’ Perceptions of the Pediatric Rheumatologist Supply

The Arthritis Foundation (AF), in conjunction with the American College of Rheumatology (ACR), created and fielded a survey of pediatric rheumatologists and internist rheumatologists in the United States in March 2004, hereafter referred to as the AF/ACR Survey.  Detailed information on this survey, including descriptive statistics, is provided in Appendix E.  In this survey, pediatric rheumatologists were asked to assess the current supply of pediatric rheumatology care locally and nationally.  Nearly two-thirds of responding pediatric rheumatologists reported a local shortage of pediatric rheumatology care and all respondents reported a national shortage of pediatric rheumatology providers (Table 5).  Responding pediatric rheumatologists were also asked to specify the average wait time for an appointment in their practice:  less than 1 week, 1 to 2 weeks, or 2 or more weeks.  Sixty-five percent of responding pediatric rheumatologists reported that the wait time for an initial patient appointment exceeded 2 weeks in their practice. 

Respondents were asked to select from among a list of potential causes of the shortage; the majority of providers indicated that poor reimbursement contributed to the current shortage.  This finding is not surprising given that Medicaid patients comprise one-third of pediatric rheumatologists’ patients and a recent study showed that the Medicaid-to-Medicare fee ratio was 0.69 (i.e., Medicaid pays 69 cents for every dollar paid by Medicare) in 2003. ¹³ Other common factors cited as contributing to the shortage included poor working conditions and salary concerns.  Among those providers who wrote a specific concern in the open-ended section (n=30), many stated that lack of exposure to pediatric rheumatology during training and lack of mentors contributed to the current shortage.

There was near universal agreement among responding pediatric rheumatologists that the current shortage had important consequences for patients, including increased wait times, delays in diagnosis and treatment, misdiagnosis, and inappropriate treatment.  Among those who responded in the open-ended section (n=11), most reported that the involvement of other physician providers (i.e., general pediatrician and internist rheumatologists) in the care of children and poor outcomes were adverse consequences of the current supply and distribution of pediatric rheumatologists.

Table 5: Pediatric Rheumatologists’ Perceptions of Workforce Shortage, AF/ACR Survey (n=104)