the state of the physician workforce - aamc · 2019. 7. 3. · number of clinical sites. supply of...
TRANSCRIPT
The State of the Physician Workforce
Michael J. DillDirector, Workforce Studies
AAMC
November 4, 2017
1
Projections
PopulationDiversity
Projections
2
Projections
Supply, demand, specialty groups
3
4
What’s new?
• Updated data
• Refined hospitalists estimates
• Updated PA & APRN supply projections
• Population health scenario
• Metro/non-metro location data for demand and
utilization equity
5
• Physician demand continues to grow faster than supply
• Projected total physician shortfall of between 40,800 and 104,900 physicians by 2030
• Shortages in both primary and specialty care – with a particularly large shortage in surgical specialties
• Consistent with 2015 & 2016 projections reports
Key takeaways from the updated projections
6
Supply scenarios include retirement, work hours, GME expansion
750,000 800,000 850,000 900,000 950,000
Projected FTE physician supply, 2030
Retire Earlier (-2)
Millennial Hours
Status Quo
GME Expansion
Retire Later (+2)
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.7
750,000 800,000 850,000 900,000 950,000 1,000,000 1,050,000 1,100,000
Projected FTE physician demand, 2030
ACA + APRN/PA High
ACA + APRN/PA Moderate
ACA + Population Health
ACA + Retail Clinics
Status Quo
ACA
ACA + MC
Demand scenarios include ACA, APRNs/PAs, population health, retail clinics, managed care
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.8
An increasing overall shortage of physicians is projected through 2030
0
30,000
60,000
90,000
120,000
2015 2020 2025 2030
Proj
ecte
d sh
orta
ge, F
TE p
hysi
cian
s
Total projected physician shortfall range, 2015-2030 104,900
40,800
2030 range
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.
9
The size and range of projected physician shortages varies by specialty group
7,300
33,500
1,300
19,800
18,600
43,100
61,800
12,000
29,000
31,8000 10,000 20,000 30,000 40,000 50,000 60,000 70,000
Primary CareSpecialties
Non-Primary Care
Medical Specialties
Surgical Specialties
Other Specialties
Projected physician specialty group shortfall ranges, 2030
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.
10
Projections
Health care utilization equity & population health
11
We model Health Care Utilization Equity to better understand magnitude of unmet need
• What if barriers disappeared? How much more utilization (in 2015)?
• People without medical insurance and people living in non-metropolitan areas => utilization patterns equivalent to their insured peers living in metropolitan areas
• Everyone => utilization patterns equivalent to white insured populations residing in metropolitan areas
Scenario 1:Insurance &
Metro/Non-metro
Scenario 2:Insurance, Metro/Non-
metro, & Race/Ethnicity
12
Estimated Additional Physicians Needed if U.S. Had Achieved Health Care Utilization Equity in 2015
Scenario 1:Insurance &
Metro/Non-metro
34,800 Additional Physicians
Scenario 2:Insurance, Metro/Non-
metro, & Race/Ethnicity
96,800Additional Physicians
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.
13
Estimated Additional Physicians Needed if U.S. Had Achieved Health Care Utilization Equity in 2015
Scenario 1(Insurance,
Metro)Primary
CareScenario 2(Insurance, metro, race)
Scenario 1(Insurance,
metro)
Scenario 2(Insurance, metro, race)
Specialty Care
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.
10,300
21,800
24,500
75,00014
We model population health measures to better understand their long term workforce implications
• Scenario models the workforce implications of achieving selected Healthy People 2020 goals
• Sustained 5% body weight loss for overweight and obese adults
• Improved blood pressure, cholesterol, and blood glucose levels for adults with elevated levels
• Smoking cessation
15
Achieving population health goals would have different short- and long-term effects on demand
• Short-term: 1% decline in physician demand• Long-term: 2% increase in physician demand (by 2030)
• Shifts in demand for select physician specialties• Shifts in utilization across delivery settings
16
Effect of achieving population health goals would differ across specialty groups
0 1,000 2,000 3,000 4,000 5,000 6,000Net change in projected FTE physician demand by 2030
Medical Specialties
Other
Surgery
Primary Care
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.
17
Projections
Underlying trends: UME18
19
US MD enrollment expected to exceed 30% increase
15,000
16,000
17,000
18,000
19,000
20,000
21,000
22,000
23,000
2002 2005 2008 2011 2014 2017 2020 2023
US
MD
FIR
ST Y
EAR
EN
RO
LLM
ENT
Original schools (n=125)
All Schools (n=145)
30% over 2002
Historical Data Survey Data Projections
Source: AAMC 2016 Medical School Enrollment Survey Report20
Overall MD & DO first year enrollment is projected to grow 59% between 2002 and 2021
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Firs
t yea
r enr
ollm
ent
Projected MD and DO first year enrollment through 2021
DO
MD
196%
35%
Source: AAMC 2016 Medical School Enrollment Survey Report21
Admissions/UME Match/GME
22
Clerkships
Medical schools are increasingly concerned about clinical training opportunities for their students
72.6%77.4%
54.0%
79.6%87.1%
73.5%
0%
20%
40%
60%
80%
100%
Number of clinical training sites Supply of qualified primary care preceptors Supply of qualified specialty preceptors
Perc
enta
ge o
f sch
ools
con
cern
ed a
bout
clin
ical
tra
inin
g op
portu
nitie
s
2010 2016
Source: AAMC 2016 Medical School Enrollment Survey Report23
Medical schools experiencing more difficulties with existing clinical training sites
11.1%17.0%
26.0%
17.0%23.8%
32.0%26.5% 28.0%
53.0%
34.9%
62.1%59.1%
0%
10%
20%
30%
40%
50%
60%
70%
High turnover amongvolunteer physicians
Difficulty in replacingretired physician
volunteers
Competition fromosteopathic medicalschools for clinical
training sites
Competition fromoffshore medical
schools for clinicaltraining sites
Competition from otherhealth care
professionals (e.g.,NPs, PAs)
Pressure from existingclinical training sites
regarding payment(s)for student rotations
Perc
enta
ge o
f sch
ools
exp
erie
ncin
g di
fficu
lties
with
ex
istin
g cl
inic
al tr
aini
ng s
ites
2009 2016Source: AAMC 2016 Medical School Enrollment Survey Report
24
25
Adequacy of clinical opportunities for students an across-the-board concern
0%
10%
20%
30%
40%
50%
60%
70%
Number of clinical sites Supply of primary care preceptors Supply specialty preceptors
Percent of programs very concerned
M.D. D.O. N.P. P.A.
Source: Recruiting and Maintaining U.S. Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/ClinicalTraining Site Survey.
26
Clerkship/clinical training sites were getting harder to develop & maintain 4 years ago
0%
10%
20%
30%
40%
50%
60%
Identify and develop new core or required training sites Maintain and preserve existing core or required training sites
Percent of programs reporting much more difficult than two years prior
M.D. D.O. N.P. P.A.
Source: Recruiting and Maintaining U.S. Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/ClinicalTraining Site Survey.
27
Projections
Underlying trends: GME28
Percentage of schools concerned about graduate medical education, 2012–2016
35%
67%
84%
47%
76%
91%
48%
71%
86%
50%
62%
77%
39%
62%
80%
FOR MY INCOMING STUDENTS IN MY STATE NATIONALLY
PERCENT OF SCHOOLS REPORTING MAJOR OR MODERATE CONCERN
2012 2013 2014 2015 2016
Source: AAMC 2016 Medical School Enrollment Survey Report29
10,000
12,500
15,000
17,500
20,000
23,000
28,000
33,000
38,000
43,000
48,000
53,000
58,000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Phys
icia
ns tu
rnin
g 65
Res
iden
ts/P
op. 6
5+ in
thou
sand
s
Residents entering ACGME Pop 65+ Physicians turning 65
Production of new physicians not keeping up with aging workforce and population
Source: ACGME, Census, AMA Physician Masterfile; US Census Bureau
+ 19%
+ 36%
+ 97%
30
Projections
Underlying trends: Physician practice
31
Numbers of new PAs and NPs still growing rapidly
Source: NCCPA; AACN.
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
NP Graduates Newly Licensed PAs
UPDATE32
The shift in physician work hours has varied by age group
30
35
40
45
50
55
60
26 to 35 yrs 36 to 45 yrs 46 to 55 yrs 56 to 65 yrs Total age 66 or older
Average physician work hours per week
1980 1990 2000 2009-2011 2012-2014
Source: Census (Decennial/ACS).33
The shift in physician work hours has varied by age group and sex
-5.8
-1.1-0.4
+0.8
+2.1
-6
-3
0
3
6
26 to 35 yrs 36 to 45 yrs 46 to 55 yrs 56 to 65 yrs 66 + yrs
Change in average male physician work hours, 1980 to 2012-2014
Source: Census (Decennial/ACS).
-3.9
+3.8
+2.5
+5.8
+3.5
-6
-3
0
3
6
26 to 35 yrs 36 to 45 yrs 46 to 55 yrs 56 to 65 yrs 66 + yrs
Change in average female physician work hours, 1980 to 2012-2014
MALE FEMALE
34
The US physician workforce is getting older
0
50,000
100,000
150,000
200,000
250,000
Age 26 to 35 Age 36 to 45 Age 46 to 55 Age 56 to 65 Age 66 or older
Number of Physicians Who Worked in Prior Year
1980 1990 2000 2010
Source: United States Census Bureau. Note: Data for 2010 are a combination of 2009, 2010, 2011 American Community Surveys. *In 2000 and 2010, “Other” includes two or more races
35
Retirement scenarios remain the most extreme physician supply projections
780,000
830,000
880,000
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
Projected FTE Physician Supply: All Physicians
Retire Later +2
GME Expansion
Status Quo
Millennial Hours
Retire Earlier -2
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.
36
From a patient perspective, we ask about:• Viewing lab results online• Making appointments online• Telephone communication• Email communication• Video communication
Technology can improve access to a wide array of services
37
Consumers report overall increases in most types of technology use
38
Largest divergence in consumers’ use of technology reported for video communication
39
Workforce
Diversity
40
0
200,000
400,000
600,000
800,000
1980 1990 2000 2010
Number of Physicians Who Worked in Prior Year
Male Female
454,539
612,549709,382
Source: United States Census BureauNote: Data for 2010 are a combination of 2009, 2010, 2011 American Community Surveys
Physician workforce in the US continues to grow and to include more female physicians
346,660
41
Physician workforce is slowly becoming more racially and ethnically diverse
Source: United States Census Bureau. Note: Data for 2010 are a combination of 2009, 2010, 2011 American Community Surveys. *In 2000 and 2010, “Other” includes two or more races
42
0
250,000
500,000
750,000
1,000,000
2000 2005 2010 2015
Number of Physicians Who Worked in Prior Year
White Black American Indian or Alaska Native
Asian or Pacific Islander Two or more major races Hispanic, any race
North Carolina makes a good case study in the need to understand workforce diversity in context
Data Source: 2015 American Community Survey 5-year Estimates; 2014 North Carolina Physician Licensure Data
43
Black or African American population and physician distributions dissimilar
Population
Data Source: 2015 American Community Survey 5-year Estimates; 2014 North Carolina Physician Licensure Data44
American Indian / Alaska Native population and physician distributions somewhat similar
Population
Data Source: 2015 American Community Survey 5-year Estimates; 2014 North Carolina Physician Licensure Data45
IMGs comprise a significant part of the nation’s physician workforce
12017 State Physician Workforce Data Report, AAMC Workforce Studies.2 2016 AAMC Report on Residents, December 2016
of 2016 active physicians were International Medical Graduates (IMGs).124.5%of 2015-2016 active residents were International Medical Graduates (IMGs).224.9%
46
Deferred Action for Childhood Arrivals (DACA) program uncertainty could impact workforce diversity
1 https://www.forbes.com/sites/brucejapsen/2017/09/05/how-trumps-move-to-end-daca-worsens-the-doctor-shortage/#738df05d5b06.
Students with DACA status:
AAMC expects increased enrollment of DACA Dreamers in 2017-2018 since most with confirmed DACA status have not yet finished their undergraduate degrees.
65 Enrolled in U.S. medical schools in the 2016-2017 year
113 Applied to U.S. medical schools for the 2016-2017 year
47
Education pipeline
Diversity
48
Small but important gains from medical school expansion
• Most expansion - highest proportions in primary care and practicing in underserved and rural areas.
• Racial and ethnic diversity of matriculants increased modestly - new schools contributed disproportionately.
Shipman, Jones, Erikson, & Sandberg. 2013. “Exploring the Workforce Implications of a Decade of Medical School Expansion: Variations in Medical School Growth and Changes in Student Characteristics and Career Plans”. Academic Medicine 88(12): 1904–1912.
49
Percentage of U.S. medical school graduates by sex, 1980-2015
Source: AAMC Data Warehouse: Student file, as of 1/7/2016.
0%
10%
20%
30%
40%
50%
60%
70%
80%
1980 1985 1990 1995 2000 2005 2010 2015
Female
Male
50
Percentage of U.S. medical school white graduates by sex, 1986-2015
Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016.
0%
10%
20%
30%
40%
50%
60%
70%
80%
1986 1990 1995 2000 2005 2010 2015
Female
Male
51
Percentage of U.S. medical school Hispanic graduates by sex, 1986-2015
Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016.
0%
10%
20%
30%
40%
50%
60%
70%
80%
1986 1990 1995 2000 2005 2010 2015
Female
Male
52
Percentage of U.S. medical school Asian graduates by sex, 1986-2015
Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016.
0%
10%
20%
30%
40%
50%
60%
70%
80%
1986 1990 1995 2000 2005 2010 2015
Female
Male
53
Percentage of U.S. medical school American Indian/Alaska Native graduates by sex, 1986-2015
Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016.
0%
10%
20%
30%
40%
50%
60%
70%
80%
1986 1990 1995 2000 2005 2010 2015
Female
Male
54
Percentage of U.S. medical school Black or African American graduates by sex, 1986-2015
Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016.
0%
10%
20%
30%
40%
50%
60%
70%
80%
1986 1990 1995 2000 2005 2010 2015
Female
Male
55
Percentage of U.S. medical school female, 1986-2015
Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016.
0%
10%
20%
30%
40%
50%
60%
70%
80%
1986 1990 1995 2000 2005 2010 2015
Hispanic Black or African American Asian White
56
After 30+ years, Black male matriculation is slowly increasing above 1980 levels
0
100
200
300
400
500
600
700
80019
8019
8119
8219
8319
8419
8519
8619
8719
8819
8919
9019
9119
9219
9319
9419
9519
9619
9719
9819
9920
0020
0120
0220
0320
0420
0520
0620
0720
0820
0920
1020
1120
1220
1320
1420
1520
1620
17
Mal
e m
atric
ulan
ts to
US
med
ical
sch
ools
, 198
0 to
201
7
Black/African American
Black Alone
Black Alone or in Combination with Another Race
Source: AAMC AMCAS APP_BIO tables. Race is only available for permanent residents. 57
Most USMD schools have programs or policies designed to recruit a diverse student body
90%
88%
60%
61%
70%
0% 25% 50% 75% 100%
Minori ty groups current ly underrepresented in medicine
Students with disadvantaged backgrounds
Students from rural communit ies
Students from underserved communit ies
Students from local underserved communit ies
Percentage of programs
Source: AAMC 2016 Medical School Enrollment Survey Report58
Recruitment programs begin in elementary school
86%
59%
42%
8%
91%
59%
23%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Four-year-university students--local
Four-year-university students--nationwide
Community college students--local
Community college students--nationwide
High school students
Middle school students
Elementary school students
Percentage of schools with specific admissions programs or policies
Source: AAMC 2016 Medical School Enrollment Survey Report59
Demand
Population
60
More absolute future growth in utilization projected from whites than other groups
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
White Black Asians, Pacific Islanders,Native Americans, and
Alaskan Natives
Hispanic
Proj
ecte
d G
row
th in
Phy
sici
an D
eman
d by
Pa
tient
Rac
e an
d Et
hnic
ity
Projected growth in FTE physician demand, 2015 to 2030
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.
61
Much faster utilization growth rates projected for other groups than for whites
10%
25%
45%49%
0%
10%
20%
30%
40%
50%
60%
White Black Asians, Pacific Islanders,Native Americans, and
Alaskan Natives
Hispanic
Proj
ecte
d G
row
th in
Phy
sici
an D
eman
d by
Pat
ient
R
ace
and
Ethn
icity
Projected percentage growth in FTE physician demand, 2015 to 2030
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.
62
The vast majority of physician demand –current and projected – is in metropolitan areas
0
50,000
100,000
150,000
200,000
250,000
300,000
PrimaryCare
MedicalSpecialties
Surgery Other
FTE physician demandMetro, 2015 Metro, 2015-2030
0
50,000
100,000
150,000
200,000
250,000
300,000
PrimaryCare
MedicalSpecialties
Surgery Other
FTE physician demandNon-metro, 2015 Non metro, 2015-2030
Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.
63
Access to care
Population
64
AAMC collects data on health care access from consumers
Source: AAMC Consumer Survey of Health Care Access (June, 2017)
7% of U.S. adults (>17
million people) could not
always get careDid not need care,
43%
Needed care last 12 months-always able to
get it, 50%Could not afford, 3%
Could not get appointment soon
enough, 1%
Could not find provider, 2%
Other, 0%Transportation problems, 1%
65
LGB individuals consistently face greater challenges accessing care
66
23
29
17
25
1412
22
14
Source: AAMC Consumer Survey of Healthcare Access.
Gay, lesbian, or bisexual
Heterosexual or straight
Access to care appears to be improving, though racial/ethnic disparities persist
0
5
10
15
20
25
30
35
White Black/AfricanAmerican
Hispanic and Other Asian Hispanic/Latino Multi-race (non-Hispanic)
AmericanIndian/Alaska
Native
Percent of respondents not always able to get care
2011 2017
Source: AAMC Consumer Survey of Health Care Access Native Hawaiian/Other Pacific Islander & Other excluded due to sample size.67
The nation’s rural population is not homogenous
68
Rural access varies by race/ethnicity
69
“The diversity of American medicine — and the conversations, ideas and breakthroughs this diversity sparks — may be one reason for our competitiveness as a global leader in biomedical research and innovation.”
- Dhruv Khullar, MD
Aaron Carroll, “Why America Needs Foreign Medical Graduates”. https://www.nytimes.com/2017/10/06/upshot/america-is-surprisingly-reliant-on-foreign-medical-graduates.html70
• Da’Shia Davis, BS• Kara Fisher, MPH• Sarah Hampton, BA• Karen Jones, MApStat• Scott Shipman, MD• Imam Xierali, PhD
• Preeti Iyer, BSE (in progress)• Michelle Ogunwole, MD
The AAMC Workforce Studies Team
71
Data Snapshots
72
Physician data reports
State and specialty rankings and data on:
• Physician Supply• UME/GME• In-State Retention
73
[email protected] www.aamc.org/workforce
2018 Health Workforce Research ConferenceTysons, VAMay 9-11, 2018
74
10,000
12,500
15,000
17,500
20,000
23,000
28,000
33,000
38,000
43,000
48,000
53,000
58,000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Phys
icia
ns tu
rnin
g 65
Res
iden
ts/P
op. 6
5+ in
thou
sand
s
Residents entering ACGME Pop 65+ Physicians turning 65
Production of new physicians not keeping up with aging workforce and population
Source: ACGME, Census, AMA Physician Masterfile; US Census Bureau
+ 19%
+ 36%
+ 97%
75
Projections
PopulationDiversity Population
Projections
Diversity
Pulling it all together
76
PROJECTIONS• SHORTAGES• NOT KEEPING UP
WITH AGING
DIVERSITY• A GOOD THING• PROGRESS• NEED MORE
PROGRESS
POPULATION• AGING• DIVERSE• DEALING WITH
DISPARITIES
Where do we go from here?
• Extent of current shortages• Work hours and retirement• PAs and APRNs• Clinical training/clerkships• Distribution solutions• Pipeline programs• Keep tracking access
77
Questions?
78