The U.S. Physician Workforce: Beyond the Numbers

1
The U.S. Physician WorkforceBeyond the
Numbers

• Richard A. Cooper, M.D.
• Leonard Davis Institute of Health Economics
• University of Pennsylvania
• National Health Forum
• Washington, DC
• February 13, 2006

2
PHYSICIAN WORKFORCE - BEYOND THE NUMBERS

• 1. High quality health care requires adequate
  numbers of high quality physicians.
• 2. The demand for health care services
  nationally will continue to mirror the pace of
  economic growth.
• 3. Variation in the health care utilization
  among states will continue to reflect regional
  differences in economic status.
• 4. Variation of health care utilization among
  small areas (hospital regions, counties) will
  continue to reflect the additional burden of
  socioeconomic disparities.
• 5. The training capacity of medical schools and
  residency programs must be enlarged commensurate
  with the future demand that flows from these
  economic and demographic realities.

3
Burden of Disease
Aging
Technology

• GROWTH of ECONOMIC CAPACITY

GROWTH of HEALTH CARE SPENDING
DEMAND for PHYSICIANS
4
Economic and demographic trends predict a
continued growth in the demand for physicians
Approx 2020-2025
?
GDP ? 2.0 per capita per year
2000?
GDP ? 1.0 ? Health spending ? 1.5 ? Health
workforce ? 1.2 ? Physician workforce ? 0.75
1929?
5
But supply will not keep up with demand.
Approx 2020-2025
?
Projected Supply
2000?
1929?
6
And the Effective Supply will even be less.
Approx 2020-2025
?
2000?
Projected Supply
Effective Supply
Age Gender Lifestyle Duty hours Career paths
1929?
7
Variation in physician supply among states will
continue to reflect differences in economic
status.
Physicians per 100,000 of Population
8
State Physician Supply and Per Capita Income 1970
Data from Reinhardt, 1975
DC Excluded
9
State Physician Supply and Per Capita Income 1996
DC Excluded
10
State Physician Supply and Per Capita Income 2004
DC Excluded
11
Constant Relationship between State Physician
Supply and Per Capita Income Spanning 35
years.1970,1996 and 2004
1970 data from Reinhardt, 1975
DC Excluded
12

• DARTMOUTH
• ? More is Worse ?
• STATES
• States with more medical specialists
• have higher costs and lower quality of care.

Baicker and Chandra, 2004
13
State Quality vs Physicians Baicker and
Chandra(Dartmouth Residuals)
More Specialists ----------------
Lower Quality
Physician variable residuals after controlling
for total physician workforce.
State Quality Rank Higher ? QUALITY ? Lower
14
State Quality vs Physicians Cooper(Actual
Data)
More Specialists ----------------
Higher Quality
Physician variable Physicians
State Quality Rank Higher ? QUALITY ? Lower
15
DARTMOUTH ? More is Worse ? SMALL AREAS Among
Hospital Referral Regions (HRRs) with similar
health status, those with the greater
expenditures do not have ? Better outcomes
? Better access to care ? Greater
satisfaction
Fisher, et al, 2003
16
306 HOSPITAL REFERRAL REGIONS (HRRs)
Milwaukee HRR
17
Demographics of HRRs MetroFisher, Ann Int
Med, 2003
87 Metro
45 Metro
Low Cost
High Cost
18
Demographics of HRRs Black Latino Fisher,
Ann Int Med, 2003
17 Black Latino
6 Black Latino
Low Cost
High Cost
19
WISCONSIN HOSPITAL REFERRAL REGIONS (HRRs)
Milwaukee HRR
20
Wisconsin HRRsHospital days per 1,000 Ages 18-64
Milwaukee HRR
21
MILWAUKEE HOSPITAL REFERRAL REGION
Poverty Corridor 42 of total
population 92 of Black population 74 of
Latino population 33 of income
22
Wisconsin HRRsHospital days per 1,000 Ages 18-64
Poverty Corridor
Milwaukee HRR
Milwaukee HRR ?minus Corridor
23
The quantity of healthcare resources determines
the frequency of use.Variations are
unwarranted because they cannot be explained
by the type or severity of illness.

• DARTMOUTH
• ? More is Worse ?
• FREQUENCY OF USE
• Supply-sensitive Services

Wennberg, BMJ 2002
24
FREQUENCY OF USEHospital Admissions in Poorest
vs. Wealthiest Zonesof Milwaukee
25

• DARTMOUTH
• ? More is Worse ?
• FREQUENCY OF USE
• Academic Medical Centers

Our analyses (of end-of-life care) found
three-fold differences in physician FTE inputs
for Medicare cohorts cared for at Academic
Medical Centers. Given the apparent
inefficiency of current physician practices, the
supply pipeline is sufficient to meet future
needs through 2020.
Goodman et al, 2005
26
Physician Inputs into End-of-Life Care at
Academic Medical CentersGoodman, et al, 2005
63 AMCs
15 AMCs Newark Chicago Houston (2) Philadelphia
(3) New York (2) Los Angeles Detroit
(2) Washington Boston Pittsburgh
NYU
27
Physician Inputs into End-of-Life Care at
Academic Medical CentersGoodman, et al, 2005
63 AMCs
15 AMCs In large urban centers
Three-fold
NYU
28
More care should yield better outcomes,
butpatients who receive the most needed care
have ? more measured burden of illness
? more unmeasured burden of illness ?
worse outcomes.
Counter-clinical Conclusion
At the extreme Intensive care units (ICUs) offer
the most needed care but have the worst
mortality.
Kahn, et al. HSR Feb 2007
29
WHATS POSSILE FOR THE FUTURE?
30
The Supply-Demand dilemma
200,000 too few physicians
Demand
Residencies capped at 1996 level
Supply
31
Increasing PGY-1 residency positions by 10,000
(40) over the next decade is essential, but
even that will not close the gap
Demand
1,000/yr 2010-2025 No change
Supply
AAMC projects 17 increase in medical school
enrollment by 2012 2,500 additional
physicians/year in 2020
32
and the gap will continue for decades.None of
us has ever experienced shortages such as these.
1,000/yr 2010-2030
Demand
Supply
No change
33
PHYSICIAN WORKFORCE -- BEYOND THE NUMBERS

• 1. The training capacity of medical schools and
  residency programs must be enlarged commensurate
  with future economic and demographic demands.
• 2. Because so much time has been lost, chronic
  shortages of physicians seem inevitable.
• 3. Inadequate domestic production will cause a
  further drain of physicians from other countries,
  principally developing countries.
• 4. An inadequate supply of physicians will lead
  to decreased access to care for the most needy
  and deficiencies in care overall.

34

• Thank you

35
(No Transcript)
36
ZIP Code ComparisonIndividual Inverse
relationship
Economic Correlates and Units of Analysis
Comparison of Nations Society Direct
relationship
US
Small Area Analyses of Counties (3,141) and HRRs
(306) are intermediate between ZIP Codes
(25,000) and States or Nations
37
Economic growth will continue, and health care
spending will continue to grow more rapidly than
the economy overall.
Cutler
CMS
NOTE Under President Bushs proposed 2007
budget, annual growth of Medicare spending would
shrink from 8.1, as currently projected, to
7.7. .
38
Had residency programs continued to expand after
1996, the US would not now be facing severe
shortages.
If PGY-1 positions had continued to increase
after 1996 at 500 per year
Demand
Supply
39
But had the 110 Rule been put into place in
1996, the current deficits would be even
greater.
Demand
Implementation of the 110 Rule in 1996
Supply