What Physician Shortage? An Evidenced-Based Perspective

1. What Physician Shortage?An Evidenced-Based Perspective David C. Goodman, MD MS Professor of Pediatrics and of Health Policy The Center for Health Policy Research Dartmouth Medical School Hanover, NH May 2009

2. 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 Workforce Research at The Center for Health Policy Resarch Support Collaborators

3. 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? The Workforce Crisis

4. 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. U.S. Workforce Policy: From Surplus to Shortage

5. International Medical Grads ~6,000 per year Medicare GME: ~$8 billion plus Medicaid $$ Total Revenue $~60 billion less care/research $~19 b Increase Graduate Medical Education Increase US Medical School Enrollment Physician Training - 2000 Graduate Med Education entry = ~22,000 per yr Clinical Practice US Medical Grads ~16,000 per yr

6. 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.

7. AAMC Projected National Supply & Shortfall of Physicians with GME Expansion How large is the shortfall? Shortfall Additional Supply from Robust GME Expansion Baseline Supply Source: Salsberg. International Medical Workforce Meeting. 2008.

8. AAMC Projected National Supply & Shortfall of Physicians with GME Expansion Shortfall How large is the shortfall? Additional Supply from Robust GME Expansion Baseline Supply Source: Salsberg. International Medical Workforce Meeting. 2008.

9. Physician Supply, Demand, and Need in the U.S. 2020 1,240,000 1,173,000 1,076,000 1,086,000 1,027,00 972,000 “Shortfall” = ~90,000 or ~10% The 2020 “Shortfall” in Physicians Council on Graduate Medical Education. Sixteenth Report. 2005.

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.

11. If we agree on the desirable outcomes... Then the question is: What are the most effective and efficient ways to achieve these ends?

12. Is there evidence that access, quality, and outcomes are sensitive to physician supply, per se?

13. www.dartmouthatlas.org John Wennberg Lead Author Co-authors: Elliott Fisher, MD MPH David Goodman, MD MS Jonathan Skinner, PhD

14. 120 225 110 200 100 175 90 150 200% 80 10% 125 70 100 60 75 50 40 50 The Per Capita Supply of Physicians Varies ~200% Across Regions Specialists Generalists Dartmouth Atlas Hospital Referral Regions Post-GME clinicians per 100K population age sex adjusted - 2005

15. 215 to 316 (57) 200 to < 215 (54) 185 to < 200 (63) 170 to < 185 (67) 118 to < 170 (65) Not Populated Clinically Active Physicians per 100,000 Residentsby Hospital Referral Region (2005), age-sex adjusted

16. 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.

17. 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. Neonatologists 30 R2=0.04 * 25 * 20 Neonatologists per 10,000 births * * * * * 15 * * * * * * * * * * * * * * * * * * * 10 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 5 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 0 * 4 5 6 7 8 9 10 11 12 13 Percent Low Birth Weight Goodman, et al. Pediatrics, 2001.

18. 12.0 10.0 8.0 Cardiologists per 100K 6.0 4.0 2.0 3.0 6.0 9.0 12.0 15.0 18.0 Acute Myocardial Infarction Rate per 1,000 Medicare Enrollees Are cardiologists located where cardiac needs are greater?(306 Hospital Referral Regions, Dartmouth Atlas) There is virtually no relationship between regional physician supply and health needs. Source: Wennberg, et al. Dartmouth Cardiovascular Atlas

19. Regional variation in physician supply is not explained by: • Patient health status or health risk • Patients preference for careFisher 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

20. So what?Despite the idiosyncratic location of physicians...maybe more physicians leads to better health outcome.

21. Do areas with higher physician supply have better health outcomes? Mortality Adj.Odds Ratio • Logistic models 1995 USbirth cohort • N = 3.8 million live births • Dependent variable: 28 day mortality 1.1 Better Outcomes Inefficient Care 1 Beyond a very low supply, outcomes are insensitive to physician supply. 0.9 0.8 Very Low Low Medium High Very High Quintile of Physician Capacity in Neonatal Intensive Care Regions Neonatologists Source: Goodman, Fisher, et al. New Engl J Med, 2002.

22. With Similar Outcomes, Many Health Care Systems Deliver Care with Far Fewer PhysiciansStandardized Physician Labor Input During Last 6 Months of Life Among Medicare Cohorts(Full Time Equivalents per 1,000 beneficiaries) Source: Goodman, Wennberg, Chang, Health Affairs,March/April 2006.

23. 23.0 19.0 15.0 FTE primary care labor inputs per 1,000 11.0 7.0 3.0 FTE Primary Care Physician Labor Inputs per 1,000 Decedents During the Last Two Years of Life Cedars-Sinai Med Ctr 14.6 NYU Medical Center 13.2 Mass General 11.5 Elliot Hospital 9.8 Fletcher Allen 8.1 Catholic Med Center 7.7 Maine Medical Center 7.0 Mayo Clinic (St. Mary's) 6.8 Dartmouth-Hitchcock 6.5

24. 32.0 28.0 24.0 20.0 FTE medical specialist labor inputs per 1,000 16.0 12.0 8.0 4.0 FTE Medical Specialist Labor Inputs per 1,000 Decedents During the Last Two Years of Life Cedars-Sinai Med Ctr 31.6 NYU Medical Center 30.1 Mass General 11.7 Maine Medical Center 10.0 Mayo Clinic (St. Mary's) 8.9 Fletcher Allen 8.8 Elliot Hospital 7.7 Catholic Med Center 6.9 Dartmouth-Hitchcock 6.9

25. Are Technical Quality and Patient Satisfaction Better with More Physicians? Goodman DC, Fisher ES. New England J Med, 2008.

26. Are Technical Quality and Patient Satisfaction Better with More Physicians? Goodman DC, Fisher ES. New England J Med, 2008.

27. Why is there such a weak association between workforce supply and outcomes?

28. 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. Examples of Medical Decision Uncertainty that Lead to Different Labor Demand

29. 11.0 Minneapolis 5.0 Binghamton 4.4 Rochester 3.8 Buffalo 3.3 Syracuse 3.2 White Plains 2.7 Elmira 2.6 Albany 2.6 Miami 2.4 Manhattan 1.9 East Long Island 1.9 Bronx 1.8 9.0 7.0 Back surgery per 1,000 enrollees 5.0 3.0 1.0 Inpatient back surgery per 1,000 Medicare enrollees (2005)

30. 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?

31. 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. High Physician Supply/Cost Regions: 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.

32. 1999 Number of Atlas Regions by Physicians per 100,000 population Where do more physicians go? 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. 1979 Number of Regions Number of Atlas Regions by Physicians per 100,000 population Source: Goodman. Health Affairs, 2004.

33. 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)

34. 2019 Part A trust fund goes broke Part B and D premiums soar Medicare Costs and Non-Interest Income by Source as a Percent of GDP % GDP

35. 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? Where would you invest $5-10 billion per annum of public money in the health care system?

36. Since when did we start trusting market forces to deliver good health care?

37. 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. Does “Demand” Equal Consumer “Wants?” Medical Care Autos

38. 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.

39. 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.

40. 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.