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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. PHYSICIAN WORKFORCE - BEYOND THE NUMBERS.

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The U.S. Physician Workforce: Beyond the Numbers

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  1. 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

  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 HEALTH CARE SPENDING GROWTH of ECONOMIC CAPACITY 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 Age Gender Lifestyle Duty hours Career paths Effective Supply 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. 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

  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. “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

  29. WHAT’S 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. 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

  36. 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%..

  37. 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

  38. 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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