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Future Needs for the HIV Workforce in the U.S. ......
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"Projected workforce growth by 2019 will not accommodate the increased number of HIV-infected persons requiring care. RWHAP-funded facilities may face attrition of highly qualified providers. Dissatisfaction with salary/reimbursement and administrative burden is substantial, and black and Hispanic providers are underrepresented relative to HIV patients."
Wendy S. Armstrong, MD reviewing Weiser J et al. Clin Infect Dis 2016 Jun 29.
NEJM Journal Watch July 11, 2016
Data confirm that growth in HIV care providers will not keep pace with expected needs.
Concern about a declining HIV workforce has been raised; however, rigorous data have been unavailable. Now, investigators at the CDC have used a large HIV care surveillance system to perform a national probability sample of U.S. HIV care providers.
Among 2023 eligible physicians, physician assistants, and nurse practitioners (NPs) surveyed, 1234 responded. Of these, 58.5% are aged ≥50 or over; 24% are aged 40 to 49, and only 17.5% are younger than 40. Only 21% are black or Hispanic, despite the disproportionate number of HIV cases in these populations. Most providers are physicians trained in infectious disease (ID), followed by internal medicine and family medicine physicians, and NPs. Only 37% of providers are satisfied or very satisfied with their salary and reimbursement.
On the basis of providers' reported plans to remain or leave practice within 5 years and projected rates of those entering practice, the investigators estimated that the provider workforce would grow by 190 full-time equivalents, with an estimated increase in patient care capacity of 65,314 patients in 5 years after 2014. Given current HIV incidence and death rates, at least 100,000 additional patients are projected to require HIV care in this time.
Comment
These data support what the HIV treating community has been concerned about for several years: that the HIV workforce will have net growth, but at an inadequate rate. This finding is based on an assumption that rates of provider entry into HIV care will not change. In reality, the number of trainees entering ID has declined steeply. As the authors acknowledge, efforts to improve the care continuum and engage more hard-to-reach populations will increase the number of patients in care. These data likely represent the best-case scenario. Efforts to address the declining HIV and ID workforce are underway, as it is a public health emergency.
Dr. Armstrong is Professor of Medicine at Emory University School of Medicine and Medical Director of the Grady Infectious Diseases Program — both in Atlanta. She reports no conflicts of interest.
Note to readers: At the time NEJM Journal Watch reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
Citation(s):
1. Weiser J et al. Qualifications, demographics, satisfaction, and future capacity of the HIV care provider workforce in the United States, 2013-2014. Clin Infect Dis 2016 Jun 29; [e-pub]. (http://dx.doi.org/10.1093/cid/ciw442)
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Commentary: Infectious Diseases/Critical Care Medicine: Time to Embrace a New Subspecialty of Infectious Disease
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Qualifications, Demographics, Satisfaction, and Future Capacity of the HIV Care Provider Workforce in the United States, 2013-2014
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Abstract
Background. The human immunodeficiency virus (HIV)-infected population in the United States is increasing by about 30 000 annually (new infections minus deaths). With improvements in diagnosis and engagement in care, additional qualified HIV care providers may be needed.
Methods. We surveyed a probability sample of 2023 US HIV care providers in 2013-2014, including those at Ryan White HIV/AIDS Program (RWHAP)-funded facilities and in private practices. We estimated future patient care capacity by comparing counts of providers entering and planning to leave practice within 5 years, and the number of patients under their care.
Results. Of surveyed providers, 1234 responded (adjusted response rate, 64%): 63% were white, 11% black, 11% Hispanic, and 16% other race/ethnicity; 37% were satisfied/very satisfied with salary/reimbursement, and 33% were satisfied/very satisfied with administrative time. Compared with providers in private practice, more providers at RWHAP-funded facilities were HIV specialists (71% vs 43%; P < .0001) and planned to leave HIV practice within 5 years (11% vs 4%; P = .0004). An estimated 190 more full-time equivalent providers (defined as 40 HIV clinical care hours per week) entered practice in the past 5 years than are expected to leave in the next 5 years. If these rates continue, by 2019 patient care capacity will increase by 65 000, compared with an increased requirement of at least 100 000.
Conclusions.Projected workforce growth by 2019 will not accommodate the increased number of HIV-infected persons requiring care. RWHAP-funded facilities may face attrition of highly qualified providers. Dissatisfaction with salary/reimbursement and administrative burden is substantial, and black and Hispanic providers are underrepresented relative to HIV patients.
DISCUSSION
The HIV care provider workforce faces several challenges to meeting the needs of the growing number of HIV-infected persons requiring medical care. Racial and ethnic diversity in the workforce is limited; providers with smaller caseloads receive expert assistance relatively infrequently; providers are generally dissatisfied with salary/reimbursement and time available for documentation/administrative work; and the expected increase in workforce size and patient care capacity over 5 years will likely not keep up with increased demand [2, 3]. Providers at RWHAP-funded facilities are generally highly qualified and are more likely than those in private practice to report having plans to leave HIV practice.
Although blacks and Hispanics represent 41% and 20% of HIV-infected persons in care, respectively [4], these groups each accounted for only 11% of the HIV care provider workforce. Increasing the number of underrepresented minorities in the health professions might improve clinical outcomes and delivery of culturally competent care [16]. A nationally representative race concordance study, performed within 2 years of the introduction of protease inhibitors, found that black patients with white providers were first prescribed protease inhibitors significantly later than black patients with black providers or white patients with white providers, after adjusting for patient and provider factors [17]. The IOM, HRSA, and AAHIVM/HIVMA have advocated increased racial and ethnic diversity in the HIV care provider workforce. However, blacks and Hispanics each accounted for only 7% of medical school graduates in 2014 [18], so achieving this objective will be challenging and may require the structural changes recommended by IOM [19] and others [6, 7].
About one-third of providers cared for ≤50 patients with HIV. It is well documented that providers with HIV caseloads in this range are less likely to follow antiretroviral treatment guidelines [20-22]. Among providers with caseloads of 21-50 patients, only 1 in 5 received assistance from an HIV expert, and of providers with the smallest caseloads (≤20 patients), just half received assistance from an HIV expert. Particularly in areas with limited access to HIV specialists [23, 24], support for low-volume providers may increase adoption of HIV treatment recommendations. Pairing of providers who care for <20 patients with highly experienced providers to foster professionally supportive connections is a service of the AAHIVM Clinical Consult Program [25]. Another resource for supporting low-volume providers is the AIDS Education and Training Center Program—the training arm of the RWHAP—which is a national network of HIV experts providing education, clinical consultation, and technical assistance [26].
Only one-third of HIV care providers were satisfied with salary/reimbursement and the time for documentation/administrative work. In contrast, an American Medical Association-sponsored survey of a broad range of physicians found that few were dissatisfied with their current income [27]. Among starting salaries for medical specialties nationally in 2015, those for infectious disease specialists ranked lowest, below those of family physicians, general pediatricians, and general internists [28]. For nurse practitioners and physician assistants, obtaining HIV expertise is not associated with financial rewards [5].
RWHAP-funded outpatient facilities provide care for 73% of HIV-infected patients, many of whom are affected negatively by social determinants of health [29]. More than two-thirds of providers at RWHAP-funded facilities were HIV specialists and three-quarters had caseloads of >50 patients. Almost all provided primary care and half provided care in a language other than English. Providers at RWHAP-funded facilities and in private practice expressed low satisfaction with time for documentation/administrative work or with salary/reimbursement, but RWHAP providers were nearly 3 times as likely to report planning to leave practice in 5 years. A survey of Ryan White Part C-funded clinics found that two-thirds had difficulty recruiting HIV clinicians and cited financial compensation as a leading cause [30], which raises concerns about the potential difficulty of replacing providers who leave these practices. Structural changes recommended by HRSA [13] to increase providers' remuneration and time to complete documentation/administrative work may be needed to sustain RWHAP's highly qualified workforce.
We found no difference in HIV expertise between providers entering and leaving the field of HIV medicine, but fewer entering providers provided primary care, which is of concern considering the increasing prevalence of chronic comorbidities among HIV patients [31]. Entering providers were less satisfied with the amount of time required for documentation/administrative work and were less likely to report having sufficient time to provide HIV care for established patients. This is noteworthy, as barriers to providing quality care are a major source of physician dissatisfaction [27].
We project that the HIV care provider workforce will increase modestly over 5 years, assuming that the stable number of infectious disease and primary care postgraduate positions in the past decade is maintained [32-34]. The expected net gain of providers may add capacity to care for up to 65 000 additional patients over 5 years. However, this additional capacity will likely be outpaced by an increase in HIV prevalence of 30 000 annually if current incidence and death rates continue [2, 3], along with improvements in diagnosis and engagement in care. Even if the rate of the annual increase in HIV prevalence is reduced by one-third, this source of demand for care will still exceed the increased capacity to provide care. In addition, an estimated 124 000 people not receiving regular medical care may be newly eligible for coverage either through Medicaid or in the health insurance marketplace [35]. While 60% of providers expect to be able to care for more patients in 5 years, there are limits to providers' ability to expand their practices. Three-quarters of HIV care providers reported already devoting at least 30 hours per week to patient care.
Our analysis was subject to limitations. First, the rate of influx of providers into the field of HIV medicine during the past 5 years could increase if provider salary/reimbursement rises or administrative burden decreases relative to other fields of practice. However, these changes may take several years to implement and would therefore be unlikely to affect our calculations.
Second, estimates of the number of patients currently cared for by providers were based on self-report. To address potential bias in our estimates, we computed a weighted estimate of the total number of patients under the care of all providers; this total estimate was >1.3 million, which is substantially higher than any estimate of the in-care population in the United States [5]. This discrepancy may be due to providers counting the number of patients under their care over a period of time rather than currently, or to counting patients who are under the care of multiple providers, have transferred to another provider, or have dropped out of care. We think it likely that this inflation of caseload affects providers entering and leaving the workforce equally. Our projection that the workforce will have the capacity to provide care for an estimated 65 000 additional patients over 5 years may therefore be high, which would further support our assertion that the expected increase in provider capacity will be insufficient to accommodate the anticipated increase in demand for care.
Third, our projection of the increase in HIV prevalence in the next 5 years was based on the assumption that HIV incidence and death rates would remain stable. If newer strategies to prevent HIV transmission and improve outcomes are effective, both incidence and mortality may decrease, having a mixed effect on HIV prevalence. However, even if the near-term increase in prevalence were one-third less than what is expected, need for care would still outpace capacity.
CONCLUSIONS
The modest growth in the HIV care provider workforce capacity projected to occur by 2019 will be insufficient to meet the needs of the increased number of HIV-infected persons expected to require care. RWHAP-funded facilities may be at particular risk for inadequate capacity due to attrition of highly qualified providers. Provider dissatisfaction with salary/reimbursement and administrative burden are substantial, and racial/ethnic minority providers are underrepresented in the workforce relative to the disproportionate burden of HIV among black and Hispanic Americans.
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