LEGISLATIVE ADVOCACY
IMS JOB BANK The State of Physical Medicine & Rehabilitation in Iowa: 2000-2005
Joseph J. Chen, MD Iowa City, Iowa
Physical Medicine and Rehabilitation is the medical specialty recognized in the diagnosis and treatment of patients with acute and chronic neuro-musculo-skeletal injuries and diseases. Patients who may need physical medicine and rehabilitation care include those with brain injuries, strokes, spinal cord injuries, peripheral nerve injuries, or bone, muscle and joint problems that do no progress or are not likely to progress to requiring surgery. The specialty is wide ranging in the patients whom can benefit and includes adult and pediatric patients who have sustained devastating physical and cognitive impairments following an acute stroke, traumatic injury, or developmental disability. Physiatrists provide a broader range of medical expertise than which is currently provided by orthopaedic surgeons, physical therapists, or chiropractors for conditions including stroke, spine injury, osteoarthritis, osteoporosis, chronic pain, and debility.
Many patients, especially those who are elderly or have medically complex injuries or diseases are typically treated in an acute inpatient rehabilitation unit where physiatrists (physicians trained in physical medicine and rehabilitation) are expert leaders in the interdisciplinary care team model of teams of physical therapists, occupational therapists, speech therapists, psychologists, social workers, and rehabilitation nurses.
In the outpatient setting, physiatrists treat a diverse group of patients with chronic injury and disease such as osteoarthritis, spine and musculoskeletal pain, sports injuries, osteoporosis, neuromuscular, and other disabling problems. Physiatrist skills include knowledge about and referrals for specific physical therapy treatment approaches, prescription medication management, spinal and peripheral joint injection techniques, osteopathic manipulative treatments, orthotic or prosthetic bracing options, and referral to orthopaedic or neurosurgery colleagues when appropriate.
Iowa ranks 49th out of the 50 states and District of Columbia in the number of physical medicine and rehabilitation physicians per capita population. There is nearly a ten-fold difference in physical medicine and rehabilitation physicians per capita. Many of the early academic departments of physical medicine and rehabilitation originated at distinguished institutions such as the Rusk Institute of Rehabilitation in the New York, the Kessler Institute of Rehabilitation in New Jersey, and Temple University in Pennsylvania. Citizens from states like Washington and Minnesota with strong, reputable academic departments in physical medicine and rehabilitation also enjoy the benefits in improved access to physical medicine and rehabilitation physicians and the neuromusculoskeletal conditions they treat. Efforts to bolster the Department of Orthopaedics and Rehabilitation at the University of Iowa could improve patient access to rehabilitation physicians available at a tertiary care center.
Iowa, unfortunately, is one of several states without a physical medicine and rehabilitation residency training program which may explain its near last ranking in physiatrists per capita. There are only five residency training programs in states ranked #41-51 whereas there are 32 such residency training programs in those states that are ranked in the top 10 states. Wisconsin and Minnesota have two residency training programs, yet are ranked #8 and #10, respectively.
Nebraska is the only other Midwest state with a ranking at 45th without a residency training program in physical medicine and rehabilitation. Many of the other states are in the South. There is only 1 residency training program among the last five states ranked #47-51. Poor reimbursement, particularly Medicare reimbursement, has been a common concern among Iowa physicians. Iowa is ranked 50th in receiving only $3,414 per Medicare enrollee. Louisiana, ranked #1, receives $8,099, followed by Florida receiving $7,603, and New York receiving $7,489 per Medicare enrollee. These states receive more than twice what Iowa physicians receive for comparable services.
Since Iowa has one of the largest percentages of citizens over the age of 65 at 14.9% and ranked 4th in the nation, its low Medicare reimbursement is very problematic in terms of access of its elderly to needed physical medicine and rehabilitation services.
Conclusions:
Examination of physiatrists per capita population served indicate that more physiatrists are needed in Iowa. Further recruitment efforts should be tailored to residents completing physical medicine and rehabilitation residency training programs from other Midwest states. Recruitment of physiatrists to Iowa is essential to improve Iowa's ability to provide comprehensive rehabilitation medicine care for patients with neuromusculoskeletal conditions including stroke, spinal cord injury, spinal pain and injury, musculoskeletal deconditioning, osteoporosis, trauma rehabilitation, and many other conditions. There may still remain significant challenges in the retention of Iowa physiatrists due to Iowa's lack of a physical medicine and rehabilitation residency training program, low Medicare reimbursement and high percentage of patients over the age of 65. These factors are now causing a scarcity of physical medicine and rehabilitation services but could develop into a public health crisis "perfect storm" in the years to come.
Department of Orthopedics & Rehabilitation, University of Iowa Health Care, 200 Hawkins Drive, Iowa City, IA52242, USA, email: Joseph J. Chen
