The Looming National Physician Shortage

1
The Looming National Physician Shortage
October 26, 2007

• David T. Sakamoto, MD, MBA
• Area Health Education Center
• John A. Burns School of Medicine
• University of Hawaii

2
Consequences of not having enough providers

• Long wait time for an appointment
• Travel to visits
• Time off from work
• Dissatisfaction with care
• Forego care all together

3
(No Transcript)
4
Long term consequences to reduced access

• Diminished disease prevention, screening, early
  diagnosis treatment
• Higher emergency room utilization
• Higher hospitalization rate
• More intense treatment
• Higher cost to system
• Population that is LESS HEALTHY

5
Physician Shortage
Source Lewin Group projections for AAMC Report
(May 2007)
6
Nursing Shortage
http//bhpr.hrsa.gov/healthworkforce/reports/nursi
ng/rnbehindprojections/4.htm
7
(No Transcript)
8
Physician Workforce

• Vast majority are educated in allopathic schools
  and residency training programs
• About 17,000 physicians graduate per year
• About 24,000 physicians enter the workforce per
  year
• International Medical Graduates (IMG) comprise
  25 of the new residents

9
More Physician Workforce Facts

• 850,000 physicians in 2005 including nearly
  60,000 osteopaths.
• 2/3 of DOs enter accredited residency programs
• 25 of active physicians in the U.S. are IMGs
  about 20 of IMGs are U.S. citizens

10
Cycles in U.S. Physician Workforce

• Concerns and Policies
• 1945 late 1970s Concerned with physician
  shortages federal policy to stimulate supply
  growth
• 1980 2000 Concern with potential surpluses and
  primary care/specialist mix federal guidelines
  and encouragement to limit growth
• 2000 - 2004 Growing concern with potential
  shortages
• 2005 General consensus likelihood of shortages

11
Physician Workforce Planning U.S.

• No national level system for planning Physician
  WF
• Resistance to central control
• Market driven More than 24,000 new physicians
  each year distributed across more than 150
  specialties/sub-specialties and 50 states
• Limited federal guidelines
• Limited use of fiscal incentives
• Limited role for states in planning

12
So Why Start Now?

• Demand is likely to rise rapidly in coming
  decades
• Effective supply of physicians is likely to
  decrease
• Increasing reports of shortages in specific areas
  and specialties
• Timeframes needed to produce physicians
• Growing international concern about the migration
  of physicians from poor to rich countries

13
Time Needed to Train a Physician
14
FTE Physician Supply Up 13 2005-2020
15
Supply Factors for Physician Services

• Aging of the physician workforce (1/3 gt55)
• Productivity issues
• Generational
• Gender related
• Age related
• Earlier exit from the workforce
• New technology
• Non-physician clinicians

16
Supply Trends

• Stable physician graduation trends
• Per capita medical school enrollment has declined
  since 1980

17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
Demand Factors for Physician Services

• Growing population
• Aging
• Rising expectations
• Increasing wealth
• Higher incidence of chronic diseases perpetuated
  by lifestyle choices

21
(No Transcript)
22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
Physician Supply and DemandProjections to 2020
October 2006 U.S. Dept. Health Human
ServicesHealth Resources and Services
Admin.Bureau of Health Professions
26
Physician Supply Demand
27
(No Transcript)
28
Supply Demand by Specialty

• Primary care 18 20-30
• Cardiology 8 33-59
• Other IM 12 27-49
• Gen. Surgery -3 25-45
• OB-GYN 14 10-19
• Orthopedics 2 23-54
• Anesthesia 20 25-48
• Psychiatry 9 16-46

29
(No Transcript)
30
The Aging Population and Its Impact on the
Surgery Workforce

• David Etzioni, et. al., UCLA
• Ann. Of Surgery Vol.38(2) 170-7
• National Hospital Discharge Survey, 1996

31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
Other States/Organizations

• COGME 10 by 2020
• Merritt, Hawkins Associates 10-20
• California 4.7-15.9 by 2015
• Michigan 20 by 2020
• Massachusetts 10-20 by 2020
• Arizona, Florida, Wisconsin, Texas, Oregon, North
  Carolina, Mississippi, Iowa
• HRSA 10-20 Across the Board

36
Other Demand Factors The Great Unknowns

• State of the economy
• Technological advances
• Overall population health
• Non-physician clinicians
• Reimbursement rate
• Healthcare Reform

37
AAMC Identify and Monitor Supply/Demand Trends,
Forces

• How we use physician services over time
• Impact of changes in specialty mix
• Influence of economic incentives/disincentives
• Impact of healthcare education policy

• Physician productivity
• Workforce composition
• Information technology
• Use of non-physician clinicians
• Technological advances
• Overall population health
• Healthcare Reform

38
Solutions

• Increase Supply
• Train more
• Find more
• Increase productivity
• Change the model of care
• Keep them going longer
• Reduce Demand
• Keep people healthy (compression of morbidity)
• Ration care
• Ruin the economy

39
(No Transcript)
40
States with the Most Doctors

• 40 of the top 100 cities with strong Arts and
  Cultural programs were in the 10 states with the
  highest per capita number of doctors.
• None of the top 100 cities with strong Arts and
  Cultural programs were in the 10 states with the
  lowest number.

41
States with the Most Doctors

• 33 of the top 100 cities rated for Plentiful
  leisure activities were in the 10 states with
  the highest per capita number of doctors.
• 0 are in the 10 states with the lowest number.

42
States with the Most Doctors

• 48 of the top 100 cities rated for having Good
  schools were in the 10 states with the highest
  per capita number of doctors.
• 7 are in the 10 states with the lowest number.

43
States with the Most Doctors

• The average median income for the ten states with
  the lowest per capita number of doctors for 2000
  is 54,552.
• versus 70,360 for the ten states with the
  highest per capita number of doctors.
• Seven of the top ten states for doctors also rank
  in the top ten states in percentage of households
  earning 200,000 or more.

44
States with the Most Doctors

• The average population density of the states with
  the lowest per capita amount of doctors is 29
  persons per square mile, versus 1,444 in the
  states with the highest per capita number of
  doctors.

45
A (Brief) History Lesson

• 1909 Flexner Report and the beginning of real
  4-year medical schools
• 1930 Physician/100,000 population 125
• 1945 Physician shortage and great maldistribution
• 1959 Bane Report 1963 Health Education
  Facilities Act initiates new federal funding for
  the expansion of medical education

46
More (Brief) History Lesson

• 1971 Increased federal funding causes a doubling
  of med school capacity by 1976
• 1981 The Graduate Medical Education National
  Advisory Committee (GMENAC) predicts physician
  surplus.
• 1992 The Council on Graduate Medical Education
  (COGME) warns of a greater looming surplus.

47
End of (Brief) History Lesson

• 1997 Balanced Budget Act caps the number of
  residents and fellows and recommends a 110-50-50
  policy.
• 2002 Cooper predicts a physician shortage by
  2020.
• 2005 COGME forecasts a physician shortage by
  2020.
• 2006 HRSA forecasts an across the board physician
  shortage of 10-20 by 2020.

48

• Ex 15. Growth in Physician Supply

49

Exhibit 16. FTE Physicians per 100,000 Population
50
Exhibit 17. Percentage Growth in FTE Physicians
per Capita