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The Troubled Physician Workforce:Is a physician surge the answer?
David C. Goodman, MD MS
Professor of Pediatrics and ofCommunity and Family Medicine
The Center for the Evaluative Clinical SciencesDartmouth Medical School
Hanover, NH
2007 National Health Policy Conference
CECSCenter for the EvaluativeClinical Sciences
What are the desired outcomes of medical workforce policy?
• Access to care when it is wanted and needed.
• Care that is technically excellent and personally compassionate.
• Care that improves the health and well being of patients and populations.
• Care that is affordable to the patient and to society.
The 2020 “Shortfall” and the Remedy
COGME. Sixteenth Report. 2005.
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
Supply Demand Need
1,076,000
972,000
1,240,000
1,027,00
1,173,000
1,086,000
Physician Supply, Demand, and Need in the U.S. 2020
Shortfall = ~90,000 or ~10%
Council on Graduate Medical Education:
Increase medical school enrollment by 15%.
Increase or remove Medicare Graduate Medical Ed. cap.
American Association of Medical Colleges:
Increase medical school enrollment by 30%.
Eliminate the Medicare GME cap.
The Per Capita Supply of Physicians Varies ~300% Across Regions
30
40
50
60
70
80
90
100
110
50
75
100
125
150
175
200
225
250Specialists Generalists
Post-GME clinicians per 100K population age sex race adjusted - 1996
Dartmouth Atlas Hospital Referral Regions
10%
300%
Regional variation in physician supply is not explained by:
• Patient health status or health riskChan R, et al. Pediatrics 1997.Goodman D, et al. Pediatrics 2001.Wennberg J. Ed. Dartmouth Atlas of Health Care. Various editions. 1996 - 2006.Fisher E, et al. Ann Int Med 2003.
Example 1: Are Neonatologists located where newborn needs are greater?
8.57 to 25.64 (50)6.39 to 8.57 (49)4.88 to 6.39 (51)3.55 to 4.88 (46)0.56 to 3.55 (51)
Neonatologists per 1,000 Live Births
Neonatologists
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0
5
10
15
20
25
30
4 5 6 7 8 9 10 11 12 13
Percent Low Birth Weight
Neo
nat
olo
gis
ts p
er 1
0,00
0 b
irth
s
R2=0.04
Goodman, et al. Pediatrics, 2001.
Example 1: Are Neonatologists located where newborn needs are greater?
There is virtually no relationship
between regional physician supply and health needs.
2.0
4.0
6.0
8.0
10.0
12.0
3.0 6.0 9.0 12.0 15.0 18.0
AMI Rate per 1,000 Medicare Enrollees
Car
dio
log
ists
per
100
K
Source: Wennberg, et al. Dartmouth Cardiovascular Atlas
There is virtually no relationship
between regional physician supply and health needs.
Example 2: Are Cardiologists located where cardiac needs are greater?
Regional variation in physician supply is not explained by:
• Patient health status or health risk• Patients preference for care
Fisher E, et al. Ann Int Med 2003.NIA-CMS beneficiary survey, forthcoming.
No difference in preferences for aggressive care (dying in hospital, mechanical ventilation, or drugs that would lengthen their life, but make them feel worse)
No differences in concerns about getting too little (or too much) treatment
Somewhat lower preference for palliative care that would shorten life (80% want it in low spending regions, 75% in high spending).
So what?
Maybe more physicians leads to better health outcome.
Example 3: Do areas with higher physician supply have better health outcomes?
Source: Goodman, et al. New Engl J Med, 2002
• Logistic models 1995 USbirth cohort
• N = 3.8 million live births
• Dependent variable:28 day mortality
Very Low Low Medium High Very High0.8
0.9
1
1.1
Mortality Odds ratio
Quintile of Physician Capacity
Neonatologists
Better Outcomes Inefficient Care
Beyond a very low supply, outcomes are
insensitive to physician supply.
Last 6 Months of Life Chronic Disease Medicare Cohorts(Full Time Equivalents per 1,000 beneficiaries)
Total Primary Care
Medical Specialists
NYU Medical Center 28.3 FTE 8.8 FTE 15.0 FTE
RWJ University Hosp 19.8 4.3 12.2
Montefiore Med Center 16.5 6.5 7.1
MA General Hospital 15.3 6.3 5.5
Johns Hopkins Hospital 12.2 5.0 3.9
Yale-New Haven 10.6 3.4 4.4
UC, San Francisco 9.4 4.7 3.2
Mayo, Rochester MN 8.9 3.0 3.9
Source: Goodman, Health Affairs,March/April 2006.
Example 4: Are health outcomes related to physician labor inputs?
So what?
Would a physician surge cause any harm?
Where do more physicians go?
1979
1999
Source: Goodman. Health Affairs, 2004.
For every physician that settled in a low supply
region, 4 physicians settled in a high supply region.
High Physician Supply Regions:
• High bed capacity, medical admission rates.
• High physician visit rates.
• High intensity care at the end of life.
• High costs.
• Lower perceived access.
• No better patient satisfaction.
• Worse technical quality.
• Greater tendency for physicians to use aggressive instead of conservative treatment.
• Physicians perceive care to be less available, less able to provide quality care.
• No better and perhaps worse patient outcomes.Sirovich B, et al. Ann Int Med 2006.
Wennberg J. Ed. Dartmouth Atlas of Health Care. Various editions. 1996 - 2006.
Fisher E, et al. Ann Int Med 2003.Fisher E, at al. Health Affairs 2004.Fisher E, et al. Health Affairs 2005.Goodman D, et al. Health Affairs 2006.
Where would you invest $5 billion per annum of public money in the
health care system?
• Improvements in care systems in an effort to improve quality.• Rewarding health care systems for improved outcomes.• Implementation of the U.S. Preventive Services Task Force
recommendations.• Expanding insurance coverage to children (S-CHIP).• Health insurance for returning Iraq war vets who aren't covered at
their jobs.• Establishment of effective post-marketing surveillance system for
drugs / devices.• Increasing physician training rates?
The Center for the Evaluative Clinical SciencesDartmouth Medical School
• John Wennberg, MD MPH • Elliott Fisher, MD MPH• George Little, MD• Therese Stukel, PhD• Jonathan Skinner, PhD• Katherine Baiker, PhD• Julie Bynum, MD• Scott Shipman, MD MPH• Douglas Staiger, PhD• Amitabh Chandra, PhD• James Weinstein, MD MS• David Wennberg, MD MPH• Sally Sharp, SM• Stephanie Raymond• Phyllis Wright-Slaughter, MHA• Daniel Gottlieb, MS• Kristen Bronner, MA• Vin Fusca, MMS• Megan McAndrews, MBA, MS• David Bott, PhD• Stephen Mick, PhD (VCU) • Chiang-hua Chang, MS• Nancy Marth, MS• Jon Lurie, MD MS• Ken Schoendorf, MD MPH (CDC/NCHS)
• The Robert Wood Johnson Foundation
• Health Resources and Services Administration
• WellPoint Foundation
• Aetna Foundation
• United Health Foundation
• California HealthCare Foundation
• National Institute on Aging
Collaborators Support