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The U.S. Physician Workforce: Beyond the Numbers. Richard A. Cooper, M.D . Leonard Davis Institute of Health Economics University of Pennsylvania National Health Forum Washington, DC February 13, 2006. PHYSICIAN WORKFORCE - BEYOND THE NUMBERS.

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the u s physician workforce beyond the numbers

The U.S. Physician Workforce:Beyond the Numbers

Richard A. Cooper, M.D.

Leonard Davis Institute of Health Economics

University of Pennsylvania

National Health Forum

Washington, DC

February 13, 2006

slide2

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.

growth of economic capacity

Burden of Disease

Aging

Technology

GROWTH of HEALTH CARE

SPENDING

GROWTH of ECONOMIC CAPACITY

DEMAND for

PHYSICIANS

economic and demographic trends predict a continued growth in the demand for physicians
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

but supply will not keep up with demand
But supply will not keep up with demand.

Approx 2020-2025

Projected Supply

2000

1929

and the effective supply will even be less
And the “Effective Supply” will even be less.

Approx 2020-2025

2000

Projected Supply

Age

Gender

Lifestyle

Duty hours

Career paths

Effective Supply

1929

slide7

Variation in physician supply among states will

continue to reflect differences in economic status.

Physicians per

100,000 of Population

state physician supply and per capita income 1970
State Physician Supply and Per Capita Income 1970

Data from Reinhardt, 1975

DC Excluded

slide11
Constant Relationship between State Physician Supply and Per Capita Income Spanning 35 years.1970,1996 and 2004

1970 data from Reinhardt, 1975

DC Excluded

slide12

DARTMOUTH

 More is Worse

STATES

“States with more medical specialists

have higher costs and lower quality of care.”

Baicker and Chandra, 2004

state quality vs physicians baicker and chandra dartmouth residuals
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

state quality vs physicians cooper actual data
State Quality vs Physicians Cooper(Actual Data)

More

Specialists

----------------

Higher

Quality

Physician variable = Physicians

State Quality Rank

Higher  QUALITY  Lower

slide15

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

demographics of hrrs black latino fisher ann int med 2003
Demographics of HRRs% Black + Latino Fisher, Ann Int Med, 2003

17% Black + Latino

6% Black + Latino

Low Cost

High Cost

slide21

MILWAUKEE HOSPITAL REFERRAL REGION

“Poverty Corridor”

42% of total population

92% of Black population

74% of Latino population

33% of income

wisconsin hrrs hospital days per 1 000 ages 18 6422
Wisconsin HRRsHospital days per 1,000 Ages 18-64

Poverty Corridor

Milwaukee HRR

Milwaukee HRR

minus “Corridor”

slide23

DARTMOUTH

 More is Worse

  • FREQUENCY OF USE
  • “Supply-sensitive Services”

“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.”

Wennberg, BMJ 2002

slide25

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

physician inputs into end of life care at academic medical centers goodman et al 2005
“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

physician inputs into end of life care at academic medical centers goodman et al 200527
“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

slide28

“Counter-clinical Conclusion”

More care should yield better outcomes, but……patients who receive the most needed care have ▪ more measured burden of illness ▪ more unmeasured burden of illness ▪ worse outcomes.

At the extreme: Intensive care units (ICUs) offer

the most needed care but have the worst mortality.

Kahn, et al. HSR Feb 2007

the supply demand dilemma
The Supply-Demand dilemma

200,000 too few physicians

Demand

Residencies capped at 1996 level

Supply

slide31
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

and the gap will continue for decades none of us has ever experienced shortages such as these
…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

slide33

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.

zip code comparison individual inverse relationship

Economic Correlates and Units of Analysis

ZIP Code Comparison“Individual” Inverse relationship

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

slide37
Economic growth will continue, and health care spending will continue to grow more rapidly than the economy overall.

Cutler

CMS

NOTE: Under President Bush’s proposed 2007 budget, annual growth of Medicare spending would “shrink” from 8.1%, as currently projected, to 7.7%..

slide38
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

but had the 110 rule been put into place in 1996 the current deficits would be even greater
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

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