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What Physician Shortage?An Evidenced-Based Perspective
David C. Goodman, MD MS
Professor of Pediatrics and ofHealth Policy
The Center for Health Policy ResearchDartmouth Medical School
Hanover, NH
May 2009
Workforce Research at The Center for Health Policy Resarch
• John Wennberg, MD MPH • Elliott Fisher, MD MPH• Sam Finlayson, MD MS• Chiang-hua Chang, MS• George Little, MD• Therese Stukel, PhD• Jonathan Skinner, PhD• Julie Bynum, MD• Scott Shipman, MD MPH• Douglas Staiger, PhD• James Weinstein, MD MS• Dongmei Wang, MS• Sally Sharp, SM• Stephanie Raymond• Phyllis Wright-Slaughter, MHA• Daniel Gottlieb, MS• Kristen Bronner, MA• Megan McAndrews, MBA, MS• David Bott, PhD• Stephen Mick, PhD (VCU) • Jia Lan, MS• Nancy Marth, MS• Jon Lurie, MD MS• Ken Schoendorf, MD MPH (CDC/NCHS)
• The Robert Wood Johnson Foundation
• Mithoefer Center for Rural Surgery
• National Institute on Aging
• Health Resources and Services Administration
• WellPoint Foundation
• Aetna Foundation
• United Health Foundation
• California HealthCare Foundation
Collaborators Support
The Workforce Crisis
• Why do many believe that there is a workforce crisis?
• Would patients benefit from higher physician training rates?
• Should we “interfere” with market forces?
• How should we build our workforce and training programs?
U.S. Workforce Policy: From Surplus to Shortage
• 1997: Surplus of physicians.
• 2005: Council on Graduate Medical Education 16th report declares an impending physician shortage.
• 2006: AAMC recommends 30% increase in medical school enrollment and lifting of the Medicare GME funding cap.
Physician Training - 2000
US Medical Grads~16,000 per yr
Graduate Med Educationentry = ~22,000 per yr
Clinical Practice
International Medical Grads~6,000 per year
IncreaseGraduate Medical
Education
Medicare GME: ~$8 billionplus Medicaid $$
IncreaseUS Medical School
Enrollment
Total Revenue $~60 billionless care/research $~19 b
What is the evidence for an impending shortage?
• Growing population, particularly of the elderly.
• Increases in age-specific utilization rates.
• Economic expansion: “GDP is destiny”.
• In other words, “demand” is increasingly rapidly; failing to anticipate “demand” with more physicians will lead to a shortage.
AAMC Projected National Supply & Shortfall of Physicians with GME Expansion
Source: Salsberg. International Medical Workforce Meeting. 2008.
Baseline Supply
Additional Supply from
Robust GME Expansion
Shortfall
How large is the shortfall?
AAMC Projected National Supply & Shortfall of Physicians with GME Expansion
Source: Salsberg. International Medical Workforce Meeting. 2008.
Baseline Supply
Additional Supply from Robust GME Expansion
Shortfall
How large is the shortfall?
The 2020 “Shortfall” in Physicians
Council on Graduate Medical Education. 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%
An alternative approach:What are the desirable outcomes of investing
in the medical workforce?
• Access: to care when it is wanted and needed.
• Quality: Care that is technically excellent and personally compassionate.
• Outcomes: Care that improves the health and well being of patients and populations.
• Costs: Care that is affordable to the patient and to society.
If we agree on the desirable outcomes...
Then the question is:
What are the most effective and efficient ways to achieve these ends?
Is there evidence that access, quality, and outcomes are sensitive
to physician supply, per se?
www.dartmouthatlas.org
John Wennberg Lead Author
Co-authors:
Elliott Fisher, MD MPH
David Goodman, MD MS
Jonathan Skinner, PhD
The Per Capita Supply of Physicians Varies ~200% Across Regions
Post-GME clinicians per 100K population age sex adjusted - 2005
Dartmouth Atlas Hospital Referral Regions
50
75
100
125
150
175
200
225Specialists Generalists
10%
200%
40
50
60
70
80
90
100
110
120
Clinically Active Physicians per 100,000 ResidentsClinically Active Physicians per 100,000 Residentsby Hospital Referral Region (2005), age-sex adjustedby Hospital Referral Region (2005), age-sex adjusted
215215 to to 316316 (57)(57)200200 to < to < 215215 (54)(54)185185 to < to < 200200 (63)(63)170170 to < to < 185185 (67)(67)118118 to < to < 170170 (65)(65)Not PopulatedNot Populated
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.
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
nato
logi
sts
per
10,
000
birt
hs R2=0.04
Goodman, et al. Pediatrics, 2001.
Are neonatologists located where newborn needs are greater?
(246 Neonatal Intensive Care Regions)
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
Acute Myocardial InfarctionRate per 1,000 Medicare Enrollees
Car
diol
ogis
ts p
er 1
00K
Source: Wennberg, et al. Dartmouth Cardiovascular Atlas
There is virtually no relationship between regional physician supply and health
needs.
Are cardiologists located where cardiac needs are greater?(306 Hospital Referral Regions, Dartmouth Atlas)
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
So what?
Despite the idiosyncratic location of physicians...
maybe more physicians leads to better health outcome.
Do areas with higher physician supply have better health outcomes?
Source: Goodman, Fisher, 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 Adj.Odds Ratio
Quintile of Physician Capacity in Neonatal Intensive Care Regions
Neonatologists
Better Outcomes Inefficient Care
Beyond a very low supply, outcomes are
insensitive to physician supply.
With Similar Outcomes, Many Health Care Systems Deliver Care with Far Fewer Physicians
Standardized Physician Labor Input During Last 6 Months of Life Among Medicare Cohorts
(Full Time Equivalents per 1,000 beneficiaries)
Mean Age
Total FTEs Primary Care
Medical Specialists
NYU Medical Center 82 28.3 8.8 15.0
RWJ University Hospital (NJ) 80 19.8 4.3 12.2
Montefiore Med Center (NY) 83 16.5 6.5 7.1
MA General Hospital 80 15.3 6.3 5.5
Johns Hopkins Hospital 77 12.2 5.0 3.9
Yale-New Haven 82 10.6 3.4 4.4
UC, San Francisco 81 9.4 4.7 3.2
Mayo, Rochester MN 81 8.9 3.0 3.9
Strong Memor., Rochester,NY 81 8.1 3.8 2.4
Source: Goodman, Wennberg, Chang, Health Affairs,March/April 2006.
FTE Primary Care Physician Labor Inputs per 1,000 Decedents During the Last Two Years of Life
3.03.0
7.07.0
11.011.0
15.015.0
19.019.0
23.023.0
FT
E p
rimar
y ca
re la
bor
inpu
ts p
er 1
,000
FT
E p
rimar
y ca
re la
bor
inpu
ts p
er 1
,000
Cedars-Sinai Med Ctr 14.6NYU Medical Center 13.2Mass General 11.5Elliot Hospital 9.8Fletcher Allen 8.1Catholic Med Center 7.7Maine Medical Center 7.0Mayo Clinic (St. Mary's) 6.8Dartmouth-Hitchcock 6.5
FTE Medical Specialist Labor Inputs per 1,000 Decedents During FTE Medical Specialist Labor Inputs per 1,000 Decedents During the Last Two Years of Lifethe Last Two Years of Life
4.04.0
8.08.0
12.012.0
16.016.0
20.020.0
24.024.0
28.028.0
32.032.0
FT
E m
edic
al s
peci
alis
t la
bor
inpu
ts p
er 1
,000
FT
E m
edic
al s
peci
alis
t la
bor
inpu
ts p
er 1
,000
Cedars-Sinai Med Ctr 31.6NYU Medical Center 30.1Mass General 11.7Maine Medical Center 10.0Mayo Clinic (St. Mary's) 8.9Fletcher Allen 8.8Elliot Hospital 7.7Catholic Med Center 6.9Dartmouth-Hitchcock 6.9
Are Technical Quality and Patient Satisfaction Better with More Physicians?
Physicians Per Capita
Lowest Quintile
Highest Quintile
Ratio highest to
lowest
Total physicians per capita by Hospital Referral Regions (2005)
169.4 271.8 1.60
CMS Compare Composite Scores (2005)
Acute myocardial infarction 91.0 93.1 1.02
Congestive heart failure 84.1 88.6 1.05
Pneumonia 79.5 79.2 1.00
Goodman DC, Fisher ES. New England J Med, 2008.
Are Technical Quality and Patient Satisfaction Better with More Physicians?
Physicians Per Capita
Lowest Quintile
Highest Quintile
Ratio highest to
lowest
Total physicians per capita by Hospital Referral Regions (2005)
169.4 271.8 1.60
CMS Compare Composite Scores (2005)
Acute myocardial infarction 91.0 93.1 1.02
Congestive heart failure 84.1 88.6 1.05
Pneumonia 79.5 79.2 1.00
Medicare access and satisfaction (2005)
Ever had a problem and didn't see a doctor? (% No) 91.7 93.2 1.02
Do you have a particular place for medical care? (% Yes) 95.0 95.5 1.01
Satisfied with ease of getting to the doctor? (% Yes) 94.9 94.7 1.00
Satisfied with doctor's concern for overall health? (% Yes) 95.5 95.7 1.00
Satisfied with quality of medical care? (% Yes) 96.7 97.0 1.00
Goodman DC, Fisher ES. New England J Med, 2008.
Why is there such a weak association between workforce supply and outcomes?
Examples of Medical Decision Uncertainty that Lead to Different Labor Demand
• 84 y.o with mild CHF, diabetes, and new onset back pain that is poorly controlled with oral opiates.
– Admit to the hospital?
• 69 y.o with COPD (Nighttime O2) and two recent episodes of bronchitis with ER visits.
– Consultation with a pulmonologist? Revisit every 2, 4, 6 months?
• 65 y.o. with new lumbar disc herniation.
Inpatient back surgery per 1,000 Medicare enrollees (2005)
1.0
3.0
5.0
7.0
9.0
11.0
Bac
k su
rger
y pe
r 1,
000
enro
llees Minneapolis 5.0
Binghamton 4.4Rochester 3.8Buffalo 3.3Syracuse 3.2White Plains 2.7Elmira 2.6Albany 2.6Miami 2.4Manhattan 1.9East Long Island 1.9Bronx 1.8
So what?
Yes, physician are located idiosyncratically.
And maybe outcomes aren’t sensitive to physician supply.
Still, would an increase in physician training rates cause any harm?
High Physician Supply/Cost Regions:
• Less likely to provide primary care.
• Lower perceived access by patients.
• No better patient satisfaction.
• Worse technical quality.
• No better, and sometimes worse outcomes
• Physicians perceive care to be less available, less able to provide quality care.
Sirovich B, et al. Ann Int Med 2006. Sirovich B, et al. Arch Int Med 2005.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.
Number of Atlas Regions byPhysicians per 100,000 population
Where do more physicians go?
Source: Goodman. Health Affairs, 2004.
For every physician that settled in a low supply region, 4
physicians settled in a high supply region.
These are the regions associated with lower quality
and higher costs.1999
Number of Atlas Regions byPhysicians per 100,000 population
Num
ber
of R
egio
ns
1979
What about the costs of expanding medical schools and removing the Medicare GME
funding cap?
No published estimates...
probably an additional $5-10 billion per annum in training costs.
(NIH ~ $28 billion; CDC ~ $8 billion)
Medicare Costs and Non-Interest Income by Source as a Percent of GDP
2019 Part A trust fund goes brokePart B and D premiums soar
% GDP
Where would you invest $5-10 billion per annum of public money in the health care system?
• Implementation of the U.S. Preventive Services Task Force recommendations.
• Greater implementation of Cochrane Collaboration recommendations.
• Increasing NIH funding.• Rewarding health care systems for improved outcomes.• Expanding insurance coverage to children (S-CHIP).
• Increasing physician training rates?
Since when did we start trusting market forces to deliver good health care?
Does “Demand” Equal Consumer “Wants?”
• Consumers can judge quality.(e.g. Consumers Report)
• Lot’s of sellers.
• Consumers are the sole decider.
• Consumers pay the full price (no subsidization).
• Demand = what consumers want.
• Markets work well.
• Evidence-base is imperfect.
• Patients do not have full information.
• There are fewer “sellers.”
• Patients look to physicians to make recommendations.
• Insurers pay the price at the time of the “purchase” decision.
• Demand = utilization
• Market failure.
Autos Medical Care
Market forces are like gravity...Each help you get where you want to go,
but you wouldn’t want to throw away the steering wheel and brakes.
Restoring Accountability to Health Workforce Planning
• Decisions about numbers and specialty mix of physician training are left to each training hospital.
• Council on Graduate Medical Education has a narrow policy brief (i.e. physician training only, no dedicated staff) and consists entirely of physicians, primarily from teaching hospitals.
• Public dollars pays for most medical training.
• Permanent Health Workforce Commission
– Public interests and workforce goals should be clearly stated.
– Broad membership (nurses, public health expts., patients, docs)
– Should advice on health workforce, not just physician workforce.
– Dedicated staff support
– Increasingly regulatory responsibility to insulate the deliberations from training program and provider self-interests.
Source: Goodman DC. JAMA, September 10, 2008.
Beyond the workforce “crisis”
• Physician supply varies 2 - 3 fold, generally without differences in outcomes (health status, quality, access, satisfaction).
• Health care systems are adaptable to varying levels of physician supply.
• Expansion of physician training will be costly, and could exacerbate many of our current health care ills.
• Workforce planning in the U.S. lacks coordination and depends on the individual decisions of hundreds of teaching hospitals.
• Physician training resources should be redirected towards health systems delivering efficient care, and preference-based care.
• A robust primary care workforce is necessary but not sufficient for improved systems of care.
• The medical home can only succeed with payment reform and redesign of health care systems to integrated delivery systems.