salsberg texas stakeholder forum 4 8 08 v4

Physician Workforce Needs: The National Perspective

Presentation to:

Texas Health Care Policy Council and The Texas Medical Association 2008 Stakeholder Forum

Edward SalsbergSenior Associate Vice PresidentDirector, Center for Workforce Studies

April 8, 2008

Overview of Presentation

1. Key Workforce Trends and Findings

2. Factors Influencing Future Supply

3. Factors Influencing Future Demand

4. Comparing Future Supply and Demand

5. Beyond Overall Supply: Specialty and Geographic Distribution

6. Assessing Physician Workforce Needs

AAMC’s 2006 Workforce Position:Key Recommendations

• Expand US MD enrollment by 30% by 2015

• Expand GME and eliminate Medicare GME caps

• Expand National Health Service Corps awards by 1500/year

• Leave specialty choice up to students

• Increase the diversity of the workforce

• Study of physician distribution

Key Findings and Developments

• Continued analysis and studies confirm the likelihood of a shortage A large cohort of physicians is approaching

retirement age Younger physicians, particularly women,

appear to be working fewer hours Use of services continues to rise

• Medical school expansion and new schools under development make it likely we will reach the goal of a 30% rise in MD enrollment but not by 2015

Key Findings (continued)• Number of residency positions is growing

US MD enrollment is increasing steadily DO enrollment continues to grow rapidly IMGs, particularly US-IMGs, continue to increase

• US medical school graduates are increasingly selecting specialties with “controllable life styles” and IMGs are filling gaps

• Under almost all scenarios the nation is likely to face a shortage of physicians

• Increasing the physician supply has to be part of a multi-faceted effort to assure access to services including increased use of PAs, NPs and other health professionals

Recent Reports of Physician Shortages: Specialty Studies

• Allergy & Immunology (2000)

• Anesthesia (2003)

• Cardiology (2004)

• Child Psychiatry (2006)

• Critical Care Workforce (2006)

• Dermatology (2004)

• Emergency Medicine (2006)

• Endocrinology (2003)

• Family Medicine (2006)

• Geriatric Medicine (2007)

• Medical Genetics (2004)

• Neurosurgery (2005)

• Oncology (2007)

• Pediatric Subspecialty (2008)

• Psychiatry (2003)

• Public Health (2007)

• Rheumatology (2007)

Recent Reports of Physician Shortages: State Reports

• Michigan (2005)

• Mississippi (2003)

• Nevada (2006)

• New York (regional) (2007)

• North Carolina (2007)

• Oregon (2004)

• Texas (2002)

• Utah (2006)

• Virginia (2007)

• Wisconsin (2004)

• Alaska (2006)

• Arizona (2005)

• California (2004)

• Florida (2005)

• Georgia (2006)

• Hawaii (2008)

• Idaho (2007)

• Iowa (2007)

• Kentucky (2005)

• Maryland (2008)

• Massachusetts (2007)

Key Factors Influencing the Future Supply of Physicians

1. US Medical school enrollment

2. Osteopathic enrollment

3. Inflow of IMGs

4. GME positions

5. Aging and retirement of physicians

6. Gender and generational differences

First-Year Medical School Enrollment Projected to Increase 21% by 2012

15,000

16,000

17,000

18,000

19,000

20,000

21,000

22,000

2002 2004 2006 2008 2010 2012 2014 2016

Existing + New Schools

Existing Schools

16,488

19,909

Osteopathic

After 25 Years of No Growth, Numerous New Medical Schools Under Development or Discussion

Allopathic

New or Possible Schools since 2003




3. Inflow of IMGs

4. GME positions



First Year Enrollment in Osteopathic Schools Expected To Surpass 5,000 by 2012

Source: 2007 AACOM Enrollment Survey

3043(2002-03)

5,227(2012-13)

0

1,000

2,000

3,000

4,000

5,000

6,000

1993 1996 1999 2002 2005 2009 2012

Actual

Projected

2,035 (1993-94)

First Year MD and DO Enrollment in 2013 is Likely to be more than 5,500 (28%) Higher than in 2002

2002 2013 # and % Increase

MD 16,488 19,909 3,421 21.0%

DO 3,079 5,227+ 2,148 69.8%

_______________________________________________

Combined 19,567 25,136 5,569 28%

Source: 2007 AAMC Dean’s Enrollment Survey2007 AACOM Enrollment Survey




3. Inflow of IMGs

4. GME positions



The Number of IMGs Entering GME Has Increased More Than 25% Over The Past Decade

IMGs Entering GME*

1996-1997 5,379

1997-1998 5,414

1998-1999 5,371

1999-2000 5,905

2000-2001 6,097

2001-2002 6,170

2002-2003 6,208

2003-2004 5,985

2004-2005 6,338

2005-2006

6,570

2006-2007 6,802Change 1996 – 2006 +1423 (+26%)

Sources: 1995/96 to 2002/03 data based on Form 246 filings as of Aug. 2004.2003/04 to 2006/07 data are from AAMC GME Track.

Note: IMG numbers include Fifth Pathway




3. Inflow of IMGs

4. GME positions



Total Number of Residents in ACGME Programs is Up for the Fifth Consecutive Year

104,879

98,143

96,410

92,000

94,000

96,000

98,000

100,000

102,000

104,000

106,000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

The Overall Change: The Number Training in Most Specialties Increased Between AY 2002 and AY 2006

IM

Family Med

IM/Peds

Preventative Med

PsychiatryNeurology

SurgeryPediatrics

AnesthesiologyRadiology

EM

-400

-200

0

200

400

600

800

1000

1200

Change in Total Residents

There Has Been a Significant Shift in the Number of US MDs Training in Different ACGME Specialties

Change in Number of Residents (2002-2006)

-1500

-1000

-500

0

500

1000

1500

Anesthesiology

DiagnosticRadiology

Pathology

Psychiatry

EmerMed

IM Sub-specialties

Ped Sub-specialties

FamilyMed

InternalMed

OBGYN

Peds

IM/Peds

There Has Been a Shift of IMGs As Well – But Most Often in the Opposite Direction from US MDs

Change in Number of IMGs in Training 2002-2006

IM

Anesthesiology

Pediatrics

PsychiatryPhysical

MedPathology

General Surgery

IM Sub-specialties

OBGYN

Family Medicine

-1000

-500

0

500

1000

1500

2000




3. Inflow of IMGs

4. GME positions



The Physician Workforce is Aging:253,000 Active Physicians are Over 55

Sources: AMA Physician Characteristics and Distribution in the US, 1986 and 2008 EditionsNotes: Active physicians include residents/fellows.

1985 data excludes approximately 24,000 DOs. Prepared by AAMC Center for Workforce Studies, April 4, 2008

98

75

45

229 234

163

90

153141

153

0

50

100

150

200

250

300

Under 35 35-44 45-54 55-64 65 and Over

Nu

mbe

r of

Ph

ysic

ians

(In

tho

usan

ds)

1985 2006

The Number of Active Physicians Approaching Retirement Age is Increasing Sharply: At the Current Level of Production, the US population Will Grow Faster Than the Physician Supply by 2015

Year Active Physicians Reach Age 63

24,012(2017)

18,786(2012)

13,027(2007)

22,441(2025)

5,000

10,000

15,000

20,000

25,000

30,000

2007 2009 2011 2013 2015 2017 2019 2121 2023 2025

Nu

mb

er o

f A

ctiv

e P

hys

icia

ns

Source: AMA Physician Masterfile (January 2007)

25,000 Physicians Enter Training Each Year




3. Inflow of IMGs

4. GME positions

5. Aging and retirement physicians


The Percent of Physicians That are Female Is Rising Steadily

23%

30%34%

39%43% 44% 45% 46% 47% 49%

10%13%

15%20%

23% 24%27% 28% 30%29%

0%

10%

20%

30%

40%

50%

60%

1980 1985 1990 1995 2000 2002 2003 2004 2005 2006

Sources: AAMC Facts accessed online April 4, 2008AMA Physician Characteristics and Distribution in the US Prepared by AAMC Center for Workforce Studies, April 2008

MD Graduates: Percent Female

Patient Care MDs: Percent Female

Time for family and personal life very important to young physicians, especially women physicians

BALANCE Male Female

Time for family/personal life 66 82

Flexible scheduling 26 54

No / limited on call 25 44

Minimal practice mgmt resp 10 18

CAREER/INCOME

Practice income 43 33

Long term income potential 45 36

Opportunity to advance professionally 29 27

Source: AAMC 2006 Survey of Physicians Under 50

Percent “Very Important” to Physicians Under 50

Women More Likely to Work Part-time and to Take Extended Leave

70%

2% 5%

22%

76%

24%29%

69%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Have children Work part time Took 3+ monthsleave

Spouse/Partnerworks full time

Male Female

Source: AAMC 2006 Survey of Physicians Under 50

Female Physicians Work Fewer Hours Per Week Than Men

Source: AAMC/AMA Survey of Physicians Under 50

45 46

57575655

47 47

35

40

45

50

55

60

65

Under age 35 Age 35-39 Age 40-44 Age 45-49

Male

Female

Average Hours Per Week (Including Part-time and Full-time)

Trends in Demand and Utilization

Drivers of Future Demand for Physicians

• Population growth US Pop Growing by 25 million/decade

• Aging of the population Over 65 will double 2000-2030

Major illness/chronic illness far more prevalent among the elderly

Over 65 make twice as many physician visits as under 65

• Public expectations Baby boom generation: high resources and expectations

• Life Style factors Rates of obesity, diabetes, etc. rising rapidly

• Economic growth of the nation

• Medical advances

The Eleven Most Costly Medical Conditions: Far More Prevalent Among the Elderly and Generally Chronic

Condition US 2000

Treated Prevalence per 100,000

Spending (millions of dollars)

% in total health care spending

Heart disease 6,226 56,700 9%

Trauma 12,338 41,100 7%

Cancer 3,348 38,900 6%

Pulmonary conditions 15,526 36,500 6%

Mental disorders 8,575 34,400 5%

Hypertension 11,382 23,400 4%

Diabetes 4,260 18,300 3%

Arthritis 6,966 17,700 3%

Back problems 5,092 17,500 3%

Cerebrovascular disease

854 15,000 2%

Pneumonia 1,370 12,600 2%Total 312,000 50%

Source: Thorpe, K.E., C.S. Florence, & P. Joski (2004)Prepared by AAMC Center for Workforce Studies

Average Visits to Physicians by People Over Age 45 Have Risen Significantly Over the Past 15 Years

4.8 5.15.7

6.46.5

3.23.5

3.9

7.7

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

Under 15 15-24 25-44 45-64 65-74 75 and

Older

1990 2000 2005

Source: 1990, 2000, and 2005 NAMCS

1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2006

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2006

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Forecasting the Supply and Demand for Physicians

Center for Workforce Studies: Work in progress

Baseline Projections Yield Shortage of 123,000 FTEs in 2025

734,900729,800

858,100

805,100

680,500

550000

600000

650000

700000

750000

800000

850000

900000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

FT

E P

hys

icia

ns

(exc

l. re

sid

ents

)

Supply Demand

Even with an Increase in GME Positions, the Nation is Likely to Face a Major Shortage

650,000

700,000

750,000

800,000

850,000

900,000

2005 2010 2015 2020 2025

Year

FT

E P

hys

icia

ns

(ex

cl. r

esi

de

nts

)

Baseline Supply

ShortfallAdditional

Supply fromGME Expansion

AAMC Center for Workforce Studies; Preliminary, March 2008

What Can be Done to Better Assure Access to Care in the Future?

• Continue to increase medical school enrollment

• Increase GME positions

• Increase use of non-physician clinicians

• Improve efficiency and effectiveness, including through improved IT and EMR

• Increase inter-disciplinary education and practice (especially for non-physician clinicians)

• Design service delivery responsive to needs of younger and older physicians, such as flexible scheduling and part time work

Beyond Supply

• While a shortage is likely to disproportionately impact underserved areas and some specialties more than others, increasing supply is necessary but nor sufficient to address geographical and specialty mal-distribution

• Additional programs and policies are needed to address geographical and medical mal-distribution

Geographical Mal-Distribution: Four Strategies Being Explored

• Loan Repayment programs and other fiscal incentives to locate and practice in underserved areas

• Factors influencing the practice location decisions of resident physicians

• Expanding the role of Academic Medical Centers (AMCs) in serving underserved communities

• Structures to encourage part-time and volunteer service to underserved populations

How Texas compares to the US average

Texas USTexas Rank

Students in medical or osteopathic schools 2007-08 AY per 100,000 population

24.9 29.2 25

Residents in GME per 100,000 population

28.7 35.6 22

Active physicians per 100,000 population

197.5 249.7 42

Active primary care physicians per 100,000 population

67.7 88.1 47

Percent of medical or osteopathic school graduates retained in-state

58.6% 38.8% 2

Percent of GME residents retained in state 56.4% 47.2% 7

Percent of UME and GME retained in state 79.5% 66.0% 5

Sources: AMA Physician Masterfile (January 2007)National GME Census (2006)AAMC Student DatabasePopulation Division, U.S. Census Bureau

How to Measure and Project Physician Needs in a State

• No single correct number; needs vary based on wide range of factors such as demographics and disease patterns of population, and extent of poverty

• Can compare to benchmarks such as national average or similar states but very indirect measure of need

• Importance of considering current system and needs and desired system

• For assessing today’s needs can consider from perspective of: providers (hospitals, clinics, health plans: i.e. recruitment

difficulties) practitioners (i.e. waiting times, not taking new patients,

assessment of shortages) patients (i.e. access problems and waiting time)

• For forecasting, critical to assess projected population demographics, utilization patterns and health system

• Recommend a systematic review in the short run and a comprehensive study of needs in the state in the longer run

salsberg texas stakeholder forum 4 8 08 v4

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