the u.s. physician workforce: beyond the numbers
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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. - PowerPoint PPT PresentationTRANSCRIPT
The U.S. Physician Workforce:The U.S. Physician Workforce:Beyond the NumbersBeyond the Numbers
Richard A. Cooper, M.DRichard A. Cooper, M.D..
Leonard Davis Institute of Health EconomicsLeonard Davis Institute of Health EconomicsUniversity of PennsylvaniaUniversity of Pennsylvania
National Health ForumWashington, DC
February 13, 2006
1. High quality health care requires adequate numbers of high 1. High quality health care requires adequate numbers of high quality physicians.quality physicians.
2. The demand for health care services 2. The demand for health care services nationallynationally will continue to will continue to mirror the pace of economic growth.mirror the pace of economic growth.
3. Variation in the health care utilization among 3. Variation in the health care utilization among statesstates will continue will continue to reflect regional differences in economic status.to reflect regional differences in economic status.
4. Variation of health care utilization among 4. Variation of health care utilization among small areassmall areas (hospital (hospital regions, counties) will continue to reflect the additional burden of regions, counties) will continue to reflect the additional burden of socioeconomic disparities.socioeconomic disparities.
5. The training capacity of medical schools and residency programs 5. The training capacity of medical schools and residency programs must be enlarged commensurate with the future demand that must be enlarged commensurate with the future demand that flows from these economic and demographic realities.flows from these economic and demographic realities.
PHYSICIAN WORKFORCE - BEYOND THE NUMBERSPHYSICIAN WORKFORCE - BEYOND THE NUMBERS
GROWTH of ECONOMIC GROWTH of ECONOMIC CAPACITYCAPACITY
GROWTH of HEALTH CAREGROWTH of HEALTH CARESPENDINGSPENDING
DEMAND for DEMAND for PHYSICIANSPHYSICIANS
AgingAging
Burden of DiseaseBurden of Disease
TechnologyTechnology
100
150
200
250
300
350
400
$0 $10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
19291929
20002000
Economic and demographic trends predict a continued Economic and demographic trends predict a continued growth in the demand for physiciansgrowth in the demand for physicians
Approx 2020-2025Approx 2020-2025
GDP GDP 2.0% 2.0% per capita per yearper capita per year
GDP GDP 1.0% 1.0%
Health spending Health spending ~1.5% ~1.5%
Health workforce Health workforce ~1.2% ~1.2%
Physician workforce Physician workforce ~ 0.75% ~ 0.75%
100
150
200
250
300
350
400
$0 $10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
19291929
20002000 Projected SupplyProjected Supply
But supply will not keep up with demand. But supply will not keep up with demand.
Approx 2020-2025Approx 2020-2025
And the “And the “Effective SupplyEffective Supply” will even be less.” will even be less.
100
150
200
250
300
350
400
$0 $10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
19291929
20002000 Projected SupplyProjected Supply
Effective SupplyEffective SupplyAgeAgeGenderGenderLifestyleLifestyle
Duty hoursDuty hoursCareer pathsCareer paths
Approx 2020-2025Approx 2020-2025
Physicians per Physicians per 100,000 of Population100,000 of Population
Variation in physician supply among states will Variation in physician supply among states will continue to reflect differences in economic status.continue to reflect differences in economic status.
50
100
150
200
250
300
350
400
$10,000 $20,000 $30,000 $40,000
State Per Capita Income (1996 $)
Phy
sici
ans
per
100,
000
. o
f P
opul
atio
n
1970
State Physician Supply and Per Capita Income State Physician Supply and Per Capita Income 19701970
DC Excluded Data from Reinhardt, 1975
50
100
150
200
250
300
350
400
$10,000 $20,000 $30,000 $40,000
State Per Capita Income (1996 $)
Phy
sici
ans
per
100,
000
. o
f P
opul
atio
n
1996
State Physician Supply and Per Capita Income State Physician Supply and Per Capita Income 19961996
DC Excluded
50
100
150
200
250
300
350
400
$10,000 $20,000 $30,000 $40,000
State Per Capita Income (1996 $)
Phy
sici
ans
per
100,
000
. o
f P
opul
atio
n
2004
State Physician Supply and Per Capita Income State Physician Supply and Per Capita Income 20042004
DC Excluded
1996
R2 = 0.5273
1970
R2 = 0.5129
2004
R2 = 0.6011
50
100
150
200
250
300
350
400
$10,000 $20,000 $30,000 $40,000
State Per Capita Income (1996 $)
Phy
sici
ans
per
100,
000
. o
f P
opul
atio
n
2004
1996
1970
Constant Relationship between State Physician Supply Constant Relationship between State Physician Supply and Per Capita Income Spanning 35 years.and Per Capita Income Spanning 35 years.
1970,1996 and 20041970,1996 and 2004
1970 data from Reinhardt, 1975DC Excluded
DARTMOUTHDARTMOUTH More is WorseMore is Worse
STATESSTATES
““States with more medical specialists States with more medical specialists have higher costs and lower quality of care.”have higher costs and lower quality of care.”
Baicker and Chandra, 2004Baicker and Chandra, 2004
State Quality vs “Physicians” State Quality vs “Physicians” Baicker and ChandraBaicker and Chandra
(Dartmouth “Residuals”)(Dartmouth “Residuals”)
180
190
200
210
220
1 5 9 13 17 21 25 29 33 38 42 46 50"Ph
ysic
ian
s" p
er
10
0,0
00
of
Po
pu
latio
n
State Quality RankState Quality RankHigher Higher QUALITY QUALITY Lower Lower
MoreMoreSpecialistsSpecialists--------------------------------
LowerLowerQualityQuality
Physician variable = “residuals after Physician variable = “residuals after controlling for total physician workforce.”controlling for total physician workforce.”
160
170
180
190
200
1 5 9 13 17 21 25 29 33 38 42 46 50
Ph
ysic
ian
s p
er
10
0,0
00
of
Po
pu
latio
n
.
State Quality RankState Quality RankHigher Higher QUALITY QUALITY Lower Lower
State Quality vs Physicians State Quality vs Physicians CooperCooper
(Actual Data)(Actual Data)
MoreMoreSpecialistsSpecialists--------------------------------
HigherHigherQualityQuality
Physician variable = PhysiciansPhysician variable = Physicians
DARTMOUTHDARTMOUTH More is WorseMore is Worse
SMALL AREASSMALL AREAS
Among Hospital Referral Regions (HRRs) with Among Hospital Referral Regions (HRRs) with similarsimilar health health status, those with the greater expenditures do not havestatus, those with the greater expenditures do not have ▪ ▪ Better outcomesBetter outcomes ▪▪ Better access to careBetter access to care ▪▪ Greater satisfactionGreater satisfaction
Fisher, et al, 2003Fisher, et al, 2003
306 HOSPITAL REFERRAL REGIONS (HRRs)306 HOSPITAL REFERRAL REGIONS (HRRs)
Milwaukee HRR
0
20
40
60
80
100
1 2 3 4 5
Quintile
%
Demographics of HRRsDemographics of HRRs % Metro % Metro
Fisher, Fisher, Ann Int Med, 2003Ann Int Med, 2003
87% 87% MetroMetro
45% 45% MetroMetro
Low Low CostCost
High High CostCost
0
4
8
12
16
1 2 3 4 5
Quintile
%
Demographics of HRRsDemographics of HRRs% Black + Latino % Black + Latino
Fisher, Fisher, Ann Int Med, 2003Ann Int Med, 200317% 17%
Black + Black + LatinoLatino
6% 6% Black + Black + LatinoLatino
Low Low CostCost
High High CostCost
WISCONSIN HOSPITAL REFERRAL REGIONS (HRRs)WISCONSIN HOSPITAL REFERRAL REGIONS (HRRs)
Milwaukee HRRMilwaukee HRR
0
100
200
300
400
500
600
day/1000_1864Days per 1,000
Milwaukee HRR
Madison HRR
Greenbay HRR
Appleton HRR
Neenah HRR
Lacross HRR
Marshfield HRR
Wausau HRR
Wisconsin HRRsWisconsin HRRsHospital days per 1,000 Ages 18-64Hospital days per 1,000 Ages 18-64
Milwaukee HRR
“Poverty Corridor” 42% of total population 92% of Black population 74% of Latino population 33% of income
MILWAUKEE HOSPITAL REFERRAL REGIONMILWAUKEE HOSPITAL REFERRAL REGION
Wisconsin HRRsWisconsin HRRsHospital days per 1,000 Ages 18-64Hospital days per 1,000 Ages 18-64
0
100
200
300
400
500
600
day/1000_1864Days per 1,000
Milwaukee Corridor
Milwaukee HRR
Milwaukee HRR - Corridor
Madison HRR
Greenbay HRR
Appleton HRR
Neenah HRR
Lacross HRR
Marshfield HRR
Wausau HRR
Milwaukee HRR Milwaukee HRR
minus “Corridor”minus “Corridor”
Poverty CorridorPoverty Corridor
Milwaukee HRRMilwaukee HRR
““The quantity of healthcare resources The quantity of healthcare resources determinesdetermines the frequency of use.” the frequency of use.”
““Variations are Variations are unwarrantedunwarranted because they cannot because they cannot be explained by the type or severity of illness.” be explained by the type or severity of illness.”
Wennberg, BMJ 2002Wennberg, BMJ 2002
DARTMOUTHDARTMOUTH More is WorseMore is Worse
FREQUENCY OF USEFREQUENCY OF USE““Supply-sensitive ServicesSupply-sensitive Services””
FREQUENCY OF USEFREQUENCY OF USE
Hospital Admissions in Poorest vs. Wealthiest ZonesHospital Admissions in Poorest vs. Wealthiest Zonesof Milwaukeeof Milwaukee
0
1
2
3
4
5
6
7
8
Ratio of Poorest
toWealthiest
Zones
DiabetesAges 35-64
AsthmaAges 1-17
COPD Ages 35-64
CHF Ages 35-64
““Our analyses (of end-of-life care) found Our analyses (of end-of-life care) found three-fold three-fold differencesdifferences in physician FTE inputs for Medicare in physician FTE inputs for Medicare cohorts cared for at Academic Medical Centers. cohorts cared for at Academic Medical Centers.
Given the apparent inefficiency of current physician Given the apparent inefficiency of current physician practices, the supply pipeline is sufficient to meet practices, the supply pipeline is sufficient to meet future needs through 2020.”future needs through 2020.”
DARTMOUTHDARTMOUTH More is WorseMore is Worse
FREQUENCY OF USEFREQUENCY OF USEAcademic Medical CentersAcademic Medical Centers
Goodman et al, 2005Goodman et al, 2005
0
4
8
12
5 10 15 20 25 30
CPT-WRVU Equivalent FTE Physicians per 1,000
Number of AMCs
““Physician Inputs” into End-of-Life Care Physician Inputs” into End-of-Life Care at Academic Medical Centersat Academic Medical Centers
Goodman, et al, 2005Goodman, et al, 2005
15 AMCs15 AMCsNewarkNewarkChicagoChicagoHouston (2)Houston (2)Philadelphia (3)Philadelphia (3)New York (2)New York (2)Los AngelesLos AngelesDetroit (2)Detroit (2)Washington Washington BostonBostonPittsburghPittsburgh
NYUNYU
63 AMCs63 AMCs
0
4
8
12
5 10 15 20 25 30
CPT-WRVU Equivalent FTE Physicians per 1,000
Number of AMCs
““Physician Inputs” into End-of-Life Care Physician Inputs” into End-of-Life Care at Academic Medical Centersat Academic Medical Centers
Goodman, et al, 2005Goodman, et al, 2005
NYUNYU
63 AMCs63 AMCs
Three-foldThree-fold
15 AMCs15 AMCs
In largeIn large urbanurban centerscenters
More care should yield better outcomes, but…More care should yield better outcomes, but……patients who receive the most needed care have …patients who receive the most needed care have ▪ ▪ more measured burden of illness more measured burden of illness ▪ ▪ more more ununmeasured burden of illness measured burden of illness ▪ ▪ worse outcomes.worse outcomes.
““Counter-clinical Conclusion”Counter-clinical Conclusion”
Kahn, et al. HSR Feb 2007Kahn, et al. HSR Feb 2007
At the extreme: Intensive care units (ICUs) offer At the extreme: Intensive care units (ICUs) offer the most needed care but have the worst mortality.the most needed care but have the worst mortality.
WHAT’S POSSILE FOR THE FUTURE?WHAT’S POSSILE FOR THE FUTURE?
200
250
300
350
400
1980 1990 2000 2010 2020
Year
Phy
sici
ans
per
100,
000
of p
opul
atio
n
.
Demand
Supply
The Supply-Demand dilemmaThe Supply-Demand dilemma
200,000 200,000 too few too few
physiciansphysicians
Residencies Residencies capped at capped at 1996 level1996 level
Increasing PGY-1 residency positions by 10,000 (40%) Increasing PGY-1 residency positions by 10,000 (40%) over the next decade is essential, over the next decade is essential,
but even that will not close the gap…but even that will not close the gap…
200
250
300
350
400
1980 1990 2000 2010 2020
Year
Phy
sici
ans
per
100,
000
of p
opul
atio
n
.
Demand
Supply
+1,000/yr 2010-2025+1,000/yr 2010-2025
No changeNo change
AAMC projects AAMC projects 17% increase in 17% increase in medical school medical school
enrollment enrollment by 2012 by 2012
= 2,500 additional = 2,500 additional physicians/year in physicians/year in
20202020
……and the gap will continue for decades.and the gap will continue for decades.None of us has ever experienced shortages such as theseNone of us has ever experienced shortages such as these..
200
250
300
350
400
1980 1990 2000 2010 2020 2030 2040 2050
Year
Phy
sici
ans
per
100,
000
of p
opul
atio
n
.
Demand
Supply
+1,000/yr 2010-2030+1,000/yr 2010-2030
No changeNo change
1. The training capacity of medical schools and residency 1. The training capacity of medical schools and residency programs must be enlarged commensurate with future programs must be enlarged commensurate with future economic and demographic demands.economic and demographic demands.
2. Because so much time has been lost, chronic shortages of 2. Because so much time has been lost, chronic shortages of physicians seem inevitable.physicians seem inevitable.
3. Inadequate domestic production will cause a further drain of 3. Inadequate domestic production will cause a further drain of physicians from other countries, principally developing physicians from other countries, principally developing countries.countries.
4. An inadequate supply of physicians will lead to decreased 4. An inadequate supply of physicians will lead to decreased access to care for the most needy and deficiencies in care access to care for the most needy and deficiencies in care overall.overall.
PHYSICIAN WORKFORCE -- BEYOND THE NUMBERSPHYSICIAN WORKFORCE -- BEYOND THE NUMBERS
Thank youThank you
ZIP Code ComparisonZIP Code Comparison“Individual”“Individual”
Inverse relationship Inverse relationship
0
10
20
30
40
5,000 10,000 15,000 20,000 25,000
GDP per Capita ($ppp)
Heal
th E
mpl
oym
ent p
er 1
,000
Comparison of Nations Comparison of Nations “Society”“Society”
Direct relationship Direct relationship
Economic Correlates and Units of AnalysisEconomic Correlates and Units of Analysis
US
0
50
100
150
200
250
$- $10,000 $20,000 $30,000 $40,000 $50,000
Per Capita Income
Adm
issi
ons
per C
apita
Ages
18-
64
.
> $23,000
< $23,000
Small Area Analyses of Counties (3,141) and HRRs (306)Small Area Analyses of Counties (3,141) and HRRs (306)are intermediate between ZIP Codes (~25,000) and States or Nationsare intermediate between ZIP Codes (~25,000) and States or Nations
Economic growth will continue, and health care spending will Economic growth will continue, and health care spending will continue to grow more rapidly than the economy overall.continue to grow more rapidly than the economy overall.
0
5
10
15
20
25
30
35
1975 2000 2025 2050 2075
% o
f GD
P
CMSCMS
CutlerCutler
NOTENOTE: Under President Bush’s : Under President Bush’s proposed 2007 budget, annual growth of proposed 2007 budget, annual growth of Medicare spending would “shrink” from Medicare spending would “shrink” from 8.1%, as currently projected, to 7.7%.8.1%, as currently projected, to 7.7%. . .
200
250
300
350
400
1980 1990 2000 2010 2020
Year
Phy
sici
ans
per
100,
000
of p
opul
atio
n
.
DemandIf PGY-1 positions If PGY-1 positions had continued to had continued to
increase after 1996increase after 1996at 500 per yearat 500 per year
Supply
Had residency programs continued to expand after 1996, Had residency programs continued to expand after 1996, the US would not now be facing severe shortages.the US would not now be facing severe shortages.
200
250
300
350
400
1980 1990 2000 2010 2020
Year
Phy
sici
ans
per
100,
000
of p
opul
atio
n
.
Demand
Implementation Implementation of the 110% Rule of the 110% Rule
in 1996in 1996
Supply
But had the “110% Rule” been put into place in 1996, But had the “110% Rule” been put into place in 1996, the current deficits would be even greater.the current deficits would be even greater.