Physician
Workforce Policy Guidelines for the United States, 2000-2020
Sixteenth Report
January 2005
Table of Contents
(for
on-line viewing only) Entire Report in Adobe .pdf
The
Council on Graduate Medical Education
Members
of the Council on Graduate Medical Education
Preface
Summary
and Recommendations
Key Findings
Recommendations
Related Issues of Concern
Background
Supply
of Physicians, 2000-2020
Overview of
Methodology: Baseline Model and Factors Affecting Future Supply
New Entrants
Women in Medicine
Aging of the Physician Workforce
Separation From the the Physician Workforce
Specialty Distribution and Choices
Activity Rates
Alternative
Supply Scenarios and Assumptions
Alternative
Scenario One: Lifestyle Changes
Sensitivity
Analysis: Alternative Scenario One
Alternative
Scenario Two: Productivity Changes
Sensitivity
Analysis: Alternative Scenario Two
Alternative
Scenario Three: Hybrid Lifestyle/Productivity Changes
Sensitivity
Analysis: Alternative Scenario Three
Conclusions:
Supply of Physicians in the U.S., 2000-2020
Future
Demand for Physicians, 2000-2020
Overview of
Methodology: Baseline Model and Factors Affecting Future Demand
Alternative Demand
Scenarios and Assumptions
Alternative
Scenario One: Economic Factor
Sensitivity
Analysis: Alternative Scenario One
Alternative
Scenario Two: Changes in Age-Specific Utilization Rates
Sensitivity
Analysis: Alternative Scenario Two
Alternative
Scenario Three: Elimination of Unnecessary Services/Increased
Utilization Review
Sensitivity
Analysis: Alternative Scenario Three
Alternative
Scenarios Four and Five: Hybrid Models—Economic Expansion
and Unnecessary Services/Increased Utilization Review; Changes
in Age-Specific Utilization Rates and Unnecessary Services/Increased
Utilization Review
Conclusions:
Demand for Physicians in the U.S., 2000-2020
Future
Need for Physicians, 2000-2020
Overview of
Methodology: Baseline Model and Factors Affecting Future Need
Alternative Need
Scenarios and Assumptions
Alternative
Scenario One: Changes in Age-Specific Utilization Rates
Sensitivity
Analysis: Alternative Scenario One
Alternative
Scenario Two: Elimination of Unnecessary Services/Increased Utilization
Review
Sensitivity
Analysis: Alternative Scenario Two
Alternative
Scenario Three: Changes in Age-Specific Utilization Rates; Unnecessary
Services/Increased Utilization Review Hybrid
Sensitivity
Analysis: Alternative Scenario Three
Conclusions:
Need for Physicians in the U.S., 2000-2020
Physician
Supply, Demand, and Need, 2000-2020: Specialty Mix Issues
Supply of Generalist
and Non-Generalist Physicians: Baseline Projections
Supply Specialty
Mix Alternative Scenario One: Non-Generalist Dominant Mix
Supply Specialty
Mix Alternative Scenario Two: Generalist-Weighted Mix
Demand for Generalist
and Non-Generalist Physicians: Baseline Projections
Demand Specialty
Mix Alternative Scenario One: Non-Generalist Dominant Demand Mix
Demand Specialty Mix Alternative Scenario Two: Generalist-Weighted
Mix
Need for Generalist
and Non-Generalist Physicians
Need Specialty
Mix Alternative Scenario One: Non-Generalist Dominant Need Mix
Need Specialty Mix Alternative Scenario Two: Generalist-Weighted
Mix
Issues
Beyond the Models
Resident and
Fellow Work-Hour Restrictions
Non-Physician Clinicians (NPCs)
Boutique Medicine
Conclusions:
Physician Supply, Demand, and Need in the U.S., 2000-2020
Supply
Demand
Need
Summary
References
Tables
and Figures
Table
1. Supply of Physicians in the U.S., 2000-2020: Baseline Projections
Table
2. Projected Number of New Entrants Into the Physician Supply, 2000-2020
Table
3. FTE-to-Physician Ratio, 2000-2020
Table
4. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections: Physician Lifestyle Changes
Table
5. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections of Physician Lifestyle Changes: Sensitivity Analysis
Table
6. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections: Physician Productivity Increases
Table
7. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections of Physician Productivity Increases: Sensitivity Analysis
Table
8. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections: Hybrid Lifestyle/Productivity Changes
Table
9. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections of Hybrid Lifestyle/Productivity Changes: Sensitivity
Analysis
Table
10. Demand for Physicians in the U.S., 2000-2020: Baseline Projections
Table
11. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections: Economic Factor
Table
12. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections of Economic Factor: Sensitivity Analysis
Table
13. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections: Changes in Utilization Rates
Table
14. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections of Changes in Utilization Rates: Sensitivity Analysis
Table
15. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections: Reduction of Unnecessary Services
Table
16. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections of Reduction of Unnecessary Services: Sensitivity
Analysis
Table
17. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Four Projections: Economic Factor/Increased Utilization Review
Table
18. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Five Projections: Changes in Utilization Rates/Increased Utilization
Review
Table
19. Need for Physicians in the U.S., 2000-2020: Baseline Projections
Table
20. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections: Changes in Utilization Rates
Table
21. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections of Changes in Utilization Rates: Sensitivity Analysis
Table
22. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections: Reduction of Unnecessary Services
Table
23. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections: Sensitivity Analysis
Table
24. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections: Changes in Utilization Rates/Increased Utilization
Review
Table
25. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections: Sensitivity Analysis
Table
26. Supply of Physicians in the U.S., 2000-2020: Baseline Specialty
Projections
Table
27. Supply of Physicians in the U.S., 2000-2020, Specialty Projections:
30% Generalist/70% Non-Generalist Scenario
Table
28. Supply of Physicians in the U.S., 2000-2020, Specialty Projections:
45% Generalist/55% Non-Generalist Scenario
Table
29. Demand for Physicians in the U.S., 2000-2020, Baseline Specialty
Projections
Table
30. Demand for Physicians in the U.S., 2000-2020, Specialty Projections:
30% Generalist/70% Non-Generalist Scenario
Table
31. Demand for Physicians in the U.S., 2000-2020, Specialty Projections:
45% Generalist/55% Non-Generalist Scenario
Table
32. Need for Physicians in the U.S., 2000-2020: Baseline Specialty
Projections
Table
33. Need for Physicians in the U.S., 2000-2020, Specialty Projections:
30% Generalist/70% Non-Generalist Scenario
Table
34. Need for Physicians in the U.S., 2000-2020, Specialty Projections:
45% Generalist/55% Non-Generalist Scenario
Figure
1. Total Number of Allopathic and Osteopathic Graduates, 1980-2020
Figure
2. Change in Medical Students, Population, and Students per Population,
1980-2020
Figure
3. Age Distribution of Active Allopathic Physicians in the U.S., 1982
and 2001
Figure
4. PDM Population/Delivery Setting Matrix (Simplified)
Figure
5. Relationship Between Active Physician Supply and GDP, 1929-2000
Figure
6. Number of Americans 65 and Over and 85 and Over, 2000-2030
Figure
7. Days of Care in Short-Stay Hospitals, 1999
Figure
8. Estimates of Ambulatory Care Visits to Physician Offices and Clinics
1980, 1990, and 2000
Figure
9. Physician Supply, Demand, and Need in the U.S., 2020
The
Council on Graduate Medical Education
The Council on
Graduate Medical Education (COGME) was first authorized by Congress
in 1986 to provide an ongoing assessment of physician workforce trends,
training issues, and financing policies and to recommend appropriate
Federal and private-sector efforts to address identified needs. The
legislation calls for COGME to advise and make recommendations to
the Secretary of the Department of Health and Human Services (DHHS);
the Senate Committee on Health, Education, Labor, and Pensions; and
the House of Representatives Committee on Commerce. Section 219 of
the Department of Labor, Health and Human Services, and Education
and Related Agencies’ Appropriations Act, 2004, Public Law 102-394,
106 Stat. 1825, resulted in the Secretary of DHHS extending COGME
through the end of the fiscal year.
The legislation
specifies 17 members for the Council. Appointed individuals are to
include representatives of practicing primary care physicians, national
and specialty physician organizations, international medical graduates,
medical student and house staff associations, schools of medicine
and osteopathy, public and private teaching hospitals, health insurers,
business, and labor. Federal representation includes the Assistant
Secretary for Health, DHHS; the Administrator of the Centers for Medicare
and Medicaid Services, DHHS; and the Chief Medical Director of the
Veterans Administration.
CHARGE
TO THE COUNCIL
The charge to
COGME is broader than the name would imply. Title VII of the Public
Health Service Act, as amended, requires COGME to provide advice and
recommendations to the Secretary of DHHS and Congress on the following
issues:
- The supply
and distribution of physicians in the United States;
- Current and
future shortages or excesses of physicians in medical and surgical
specialties and subspecialties;
- Issues relating
to international medical school graduates;
- Appropriate
Federal policies with respect to the matters specified in items
1-3, including policies concerning changes in the financing of undergraduate
and graduate medical education (GME) programs and changes in the
types of medical education training in GME programs;
- Appropriate
efforts to be carried out by hospitals, schools of medicine, schools
of osteopathy, and accrediting bodies with respect to the matters
specified in items 1-3, including efforts for changes in undergraduate
and GME programs; and
- Deficiencies
and needs for improvement in databases concerning the supply and
distribution of, and postgraduate training programs for, physicians
in the United States and steps that should be taken to eliminate
those deficiencies.
In addition, the
Council is to encourage entities providing GME to conduct activities
to achieve voluntarily the recommendations of the Council specified
in item 5.
COGME
PUBLICATIONS
Since its establishment,
COGME has submitted the following reports to the Secretary of DHHS
and Congress:
Reports
- First Report
of the Council (1988);
- Second Report:
The Financial Status of Teaching Hospitals and the Underrepresentation
of Minorities in Medicine (1990);
- Third Report:
Improving Access to Health Care Through Physician Workforce Reform:
Directions for the 21st Century (1992);
- Fourth Report:
Recommendations to Improve Access to Health Care Through Physician
Workforce Reform (1994);
- Fifth Report:
Women and Medicine (1995);
- Sixth Report:
Managed Health Care: Implications for the Physician Workforce and
Medical Education (1995);
- Seventh Report:
Physician Workforce Funding Recommendations for Department of Health
and Human Services’ Programs (1995);
- Eighth Report:
Patient Care Physician Supply and Requirements: Testing COGME Recommendations
(1996);
- Ninth Report:
Graduate Medical Education Consortia: Changing the Governance of
Graduate Medical Education to Achieve Physician Workforce Objectives
(1997);
- Tenth Report:
Physician Distribution and Health Care Challenges in Rural and InnerCity
Areas (1998);
- Eleventh Report:
International Medical Graduates, The Physician Workforce and GME
Payment Reform (1998);
- Twelfth Report:
Minorities in Medicine (1998);
- Thirteenth
Report: Physician Education for a Changing Health Care Environment
(1999);
- Fourteenth
Report: COGME Physician Workforce Policies: Recent Developments
and Remaining Challenges in Meeting National Goals (1999); and
- Fifteenth Report:
Financing Graduate Medical Education in a Changing Health Care Environment
(2000).
OTHER
COGME PUBLICATIONS
- Scholar in
Residence Report: Reform in Medical Education and Medical Education
in the Ambulatory Setting (1991);
- Process by
which International Medical Graduates are Licensed to Practice in
the United States (September 1995);
- Proceeding
of the GME Financing Stakeholders Meeting (April 11, 2001) Bethesda,
Maryland;
- Public Response
to COGME’s Fifteenth Report (September 2001);
- Council on
Graduate Medical Education & National Advisory Council on Nurse
Education and Practice: Collaborative Education to Ensure Patient
Safety (February 2001);
- Council on
Graduate Medical Education: What is it? What has it done? Where
is it going? 2nd Edition (2001); and
- 2002 Summary
Report (2002).
COGME
RESOURCE PAPERS
- Preparing Learners
for Practice in a Managed Care Environment (1997);
- International
Medical Graduates: Immigration Law and Policy and the U.S. Physician
Workforce (1998);
- The Effects
of the Balanced Budget Act of 1997 on Graduate Medical Education
(2000);
- Update on the
Physician Workforce (2000);
- Evaluation
of Specialty Physician Workforce Methodologies (2000); and
- State and Managed
Care Support for Graduate Medical Education: Innovations and Implications
for Federal Policy (2004).
For more information
on COGME, visit the Council’s Web site at:
http://www.cogme.gov or contact:
Council on Graduate
Medical Education
5600 Fishers Lane, Room 9A-21
Rockville, MD 20857
Voice: (301) 443-6785
Fax: (301) 443-8890
Members
of the Council on Graduate Medical Education
Members
Chair
Carl J. Getto,
M.D.
Senior Vice President Medical Staff Affairs/Associate
Dean Hospital Affairs
University of Wisconsin Hospital & Clinics
Madison, Wisconsin
Vice
Chair
Robert L. Johnson,
M.D., Professor of Pediatrics and
Vice Chair, Department of Pediatrics
New Jersey Medical School
Division of Adolescent and Young Adult Medicine
Newark, New Jersey
Ms. Laurinda L.
Calongne
President
Robert Rose Consulting
Baton Rouge, Louisiana
William Ching,
Medical Student
New York University School of Medicine
New York, New York
Allen Irwin Hyman,
M.D., FCCM
Executive Vice President and Chief of Staff
Columbia-Presbyterian Medical Center
New York, New York
Rebecca M. Minter,
M.D.
VAMC Ann Arbor Healthcare System
Surgery Service
Ann Arbor, Michigan
Lucy Montalvo,
M.D., M.P.H.
San Diego, California
Angela D. Nossett,
M.D.
Executive Vice President
Committee of Interns and Residents (CIR)
Wilmington Family Health Center
Wilmington, California
Earl J. Reisdorff,
M.D.
Director of Medical Education
Ingham Regional Medical Center
Department of Medical Education
Lansing, Michigan
Russell G. Robertson,
M.D.
Department of Family and Community Medicine
Medical College of Wisconsin
Milwaukee, Wisconsin
Jerry Alan Royer,
M.D., M.B.A.
229 Cascade Falls Drive
Folsom, California
Susan Schooley,
M.D.
Chair, Department of Family Practice
Henry Ford Health System
Detroit, Michigan
Humphrey Taylor,
Chairman
The Harris Poll, Harris Interactive
New York, New York
Douglas L. Wood,
D.O., Ph.D., President
American Association of Colleges
of Osteopathic Medicine
Chevy Chase, Maryland
Statutory Members
Cristina Beato,
M.D.
Acting Assistant Secretary for Health
and Surgeon General
Washington, D.C.
Mark B. McClellan,
M.D., Ph.D.
Administrator, Centers for Medicare and
Medicaid Services
Department of Health and Human Services
Washington, D.C.
Robert H. Roswell,
M.D.
Undersecretary for Health
Veterans Health Administration
Department of Veterans Affairs
Washington, D.C.
Designee of
the Acting Assistant Secretary for Health
Howard Zucker,
M.D., Deputy Assistant
Secretary for Health
Department of Health and Human Services
Washington, D.C.
Designee of
the Centers for Medicare and Medicaid Services
Tzvi M. Hefter,
Director
Division of Acute Care
Centers for Medicare and Medicaid Services
Baltimore, Maryland
Designee of
the Department of Veterans Affairs
Stephanie H. Pincus,
M.D., M.B.A.
Chief Academic Affiliations Officer
Department of Veterans Affairs
Washington, D.C.
Staff, Division
of Medicine and Dentistry,
Bureau of Health Professions, HRSA
Department of Health and Human Services
Rockville, Maryland
Tanya Pagán
Raggio, M.D., M.P.H.
Executive Secretary and
Director, Division of Medicine and Dentistry (DMD)
O’Neal Walker,
Ph.D.
Chief, Dental and Special Projects Branch/DMD
Jerald M. Katzoff
Deputy Executive Secretary
C. Howard Davis,
Ph.D.
Staff Liaison
Jaime Nguyen,
M.D., M.P.H.
Staff Liaison
Eva M. Stone
Program Analyst and Committee Management Specialist
Anne Patterson
Secretary
Contractor for
Report Preparation: Edward Salsberg and Gaetano Forte
The Center for Health Workforce Studies
State University of New York at Albany
Preface
A central charge
of the Council on Graduate Medical Education (COGME) is to make policy
recommendations to the Nation with respect to the adequacy of the
supply and distribution of physicians in the United States (U.S.).
This mandate includes recommendations on current and future shortages
or excesses of physicians in the medical and surgical specialties
and subspecialties. Beginning in 1992, with its Third Report,
COGME issued a series of reports expressing concern with potential
surpluses of physicians and recommending an increase in the percent
of physicians trained and practicing as generalists. These concerns
led the Council to develop a recommendation that 110 percent of the
number of U.S. medical graduates in 1993 should enter residency training
each year (or about 19,750 physicians) and that half of these physicians
should be generalists. This recommendation became known as the “110/50-50”
goal for the physician workforce in the U.S.
In response to
changes in the health care delivery system, demographic changes in
the Nation’s population, changes in the practice of medicine,
and other developments, the Council concluded in 2002 that it was
appropriate and timely to re-assess the current and future supply,
demand, and need for physician services in America. The following
report is the result of this most recent re-assessment. In light of
limited resources, this study primarily used existing models to forecast
physician supply and demand, but also used more current data unavailable
for prior assessments.
The Nation’s
physician workforce is critical to the delivery of health care to
Americans. In consideration of this role and the high cost of educating
and training the physician workforce, ongoing tracking of workforce
needs and periodic comprehensive assessments are essential to guiding
decisions by the medical education community, prospective physicians,
policy makers, and others concerned with Americans’ health. The
Council hopes that this report will provide this guidance.
Summary
and Recommendations
The Council on
Graduate Medical Education (COGME) assessed the likely future supply,
demand, and need for physicians in the United States (U.S.) through
2020 for both generalist and non-generalist physicians. The models
used for the projections are based on historical patterns of use of
services and physician practice patterns applied to the expected U.S.
population and the physician workforce through 2020. Where changes
are occurring or have occurred in the historic patterns, this report
incorporates the best available information and discusses their likely
implications. The models used build on the physician forecasting models
of the Health Resources and Services Administration (HRSA)/Bureau
of Health Professions (BHPr).1 The use of these models
helps to ensure some consistency with prior work and facilitates comparisons
of the new forecasts with prior forecasts.
Scenarios have
been constructed around the best understanding of changes occurring
in health care and in medicine. For each scenario, the report presents
a sensitivity analysis indicating what the impact might be if that
factor were to change to a lesser or greater extent than current understanding
portends.
The report forecasts
future supply based on the age, gender, specialty distribution,
and educational background of the existing supply and current trends
in new entrants into residency training from U.S. allopathic and osteopathic
schools, from Canadian medical schools, and from foreign medical schools.
The report also forecasts future demand and need for
physician services based on the historical patterns of use of services
by age, gender, insurance status, type of area (urban or rural), and
managed care penetration. Estimates of future need are based primarily
on the assumption that the use of physician services by the uninsured
would increase to the level of those with health insurance if resources
were available to meet their needs. It is also assumed that the removal
of other barriers to use would also contribute to some increase in
service use. Further, the report presents an analysis of supply, demand,
and need for generalist and non-generalist specialties.2
This report includes
the results of the data analysis and describes methodologies used
to forecast supply, demand, and need and the potential impact of changes
in the factors that influence each of those. The report also includes
recommendations to better assure that the future supply meets future
demand and need.
KEY
FINDINGS
- Under current
production and practice patterns, the supply of practicing
physicians in the U.S. is expected to rise from 781,200 full-time
equivalent (FTE) physicians3 in 2000 to 971,800 in 2020,
a 24 percent increase. However, growth is expected to slow considerably
after 2010, reflecting increased rates of physician separation due
to the aging of the current physician workforce and the relatively
level annual number of new physician entrants since 1980. After
2015, the rate of population growth will exceed the rate of growth
in the number of physicians. The per capita number of physicians
is forecasted to rise from 283 per 100,000 Americans in 2000 to
301 in 2015 but then drop to 298 in 2020. Under alternative assumptions
regarding physician lifestyle changes (such as hours worked) and
increased productivity, the effective supply of physicians (FTEs)
may grow to nearly 1.08 million physicians in 2020. The most probable
aggregate projection suggests that the supply of physicians will
number approximately 1.02 million FTEs in 2020.
- At the same
time, for a number of reasons and under a number of scenarios and
models, the demand for physicians is likely to grow
even more rapidly over this period than the supply. It is likely
that the demand for physician services will grow to between 1.03
million and 1.24 million physicians in 2020. The three major factors
driving the increase in demand will be: a) the projected U.S. population
growth of 50 million persons (18 percent) between 2000 and 2020;
b) the aging of the population, as the number of Americans over
65 increases from 35 million in 2000 to 54 million in 2020; and
c) the changing age-specific per capita physician utilization rates,
with those under age 45 using fewer services and those over age
45 using more services.
- The need
for services, reflecting primarily the use of services under universal
insurance and increased utilization review processes, is also expected
to increase over the period. Need is projected to grow to between
1.09 and 1.17 million physicians in 2020.
- If the Nation’s
population continues to use services in the future as it has in
the past, and if physicians practice in the future as they have
in the past, then the Nation is likely to face a shortage of physicians
in the coming years.
- When
the midpoint of the projected range of future supply and demand
is used, the Nation is projected to face a shortage of about 85,000
physicians in 2020.
- When
the midpoint of the projected range of supply and need is used,
the Nation is projected to face a shortage of about 96,000 physicians
in 2020.
- The models
and alternative scenarios used to make the predictions included
a number of factors that could have a major impact on supply, demand,
and need and, consequently, on a potential gap in the physician
supply.
- Many
of these factors are likely to add to the shortage of physicians.
Some of these have been included in the report as scenarios
that could have an impact on the supply or demand for physicians.
These include the following:
- Changing
lifestyles for the newest generation of physicians, with
the possibility that new physicians will work fewer hours
than their predecessors;
- Continuation
of the rate of increase in the use of physician services
by those over 45, which has been increasing for the past
20 years, and increased use of services by the baby-boom
generation compared to prior generations; and
- Expected
increases in the Nation’s wealth that would contribute
to continued increases in the use of medical services.
Other
factors could also lead to larger shortages and are not
included in the baseline projections or alternative scenarios.
These include the following:
- A
potential increase in non-patient care activities by physicians,
including research and administrative activities;
- A potential
change in practice patterns for physicians over 50, including
a reduction in hours worked before retirement and earlier
retirement patterns;
- Possible
increases in departures from practice due to liability concerns
of physicians;
- Decreases
in hours worked by physicians in training;
- Possible
decreases in immigration of graduates of foreign medical
schools;
- Possible
increases in the number of physicians limiting the number
of patients on their panel (sometimes referred to as “boutique
medicine”);
- Advances
in genetic testing that could lead to increases in the use
of services as individuals learn they are at risk for certain
illnesses or conditions; and
- Additional
medical advances likely to keep individuals with chronic
illnesses alive longer without curing their illnesses.
- A
number of factors also may limit future shortages. These include
factors for which estimates of their impact are presented in the
report under different scenarios. These include the following:
- Increases
in productivity, such as through improved technologies and
information systems; and
- More
effective utilization review and quality assurance efforts
to weed out inappropriate or unnecessary services.
Other factors
not included in the supply, demand, and need projections
with the potential to reduce projected shortages include the following:
- Increases
in the supply and use of nurse practitioners, physician assistants,
and other non-physician clinicians;
- Increases
in costs and cost sharing; and
- Medical
breakthroughs that decrease service use.
- There
are already a growing number of reports of, and concerns with, shortages
in specific specialties. These include such specialties as radiology
(Sunshine 2001), anesthesiology (Schubert et al 2001; Miller and
Lanier 2001; Schubert et al 2003), cardiology (Foot et al 2000),
rheumatology (Boyce 2003), nephrology (Neilson et al 2001), pulmonary
disease/critical care (Angus et al 2000; Pronovost et al 2002),
and child psychiatry (Kim et al 2001).
- Although the
percentage of the Nation’s physicians who are generalists has
increased slightly over the past decade, it is currently about 38
percent, well below the 50 percent target recommended in COGME’s
Third Report. Even in the Kaiser Health Plans, only about
40 percent of their physicians in 2001 and 2002 (Weiner 2004) were
generalists. Results of surveys of new physicians completing training
in New York and California indicate that demand for generalists
is less than demand for most non-generalists, further weakening
the case for the 50 percent generalist goal (Nolan et al 2003a,
2003b).
RECOMMENDATIONS
Preamble
The State
of the Nation’s health care workforce directly affects both the
health of the American public and the economics of health care. It
is not our intent to codify or explicitly endorse the current health
care system. Given the constraints and confines of the available data,
these recommendations are a feasible and realistic approach to physician
workforce planning.
In light of the
likely gap between the expected supply, demand, and need for physicians
in the future, COGME recommends that the Nation undertake a multi-pronged
strategy that includes: a modest increase in medical education and
training capacity over the next decade; efforts to increase physician
productivity; and increased tracking and assessments of the supply,
demand, and need for physicians. In addition, because underserved
communities are most likely to be affected by shortages, COGME recommends
that the National Health Service Corps (NHSC) and other Federal programs
designed to address geographic and specialty maldistribution and to
increase diversity be expanded. Specific recommendations are presented
below.
- To meet
the future physician workforce demand and need in the U.S., COGME
recommends that:
- The
number of physicians entering residency training each year be
increased from approximately 24,000 in 2002 to 27,000 in 2015;
and
- The
distribution between generalists and non-generalists should
reflect ongoing assessments of demand; therefore, COGME does
not recommend a rigid national numerical target.
The analysis presented
in this report indicates that the Nation is likely to be facing a
shortage of physicians in the coming years, particularly in non-generalist
specialties. To begin to address this likely shortage, COGME recommends
that the total number of physicians entering residency training in
the U.S. be increased to 27,000 per year over the next decade. This
action would lead to an increase in the Nation’s physician workforce
by about 3 percent (30,000 physicians) by 2020. Although this level
of new entrants into medicine will be insufficient to meet future
needs, it is an important step.
This physician
workforce goal is presented as an absolute number rather than as a
percentage of the number of U.S. medical graduates in a specific year.
This absolute number is easier to understand and track, and therefore
should be a more useful target for the Nation. When presented as a
percentage of medical school graduates, the recommended number of
entrants into residency training is equal to 158 percent of the number
of 1993 U.S. medical graduates and 150 percent of the 2000 U.S. medical
school graduates.
Currently, approximately
37 percent of new physicians are entering generalist specialties,
and 63 percent are entering non-generalist specialties. COGME recommends
below that the Nation undertake studies to track overall specialty-specific
need, demand, and distribution and to share this information with
the medical education and training community. Specialty-specific need
and demand for physicians are likely to vary over time and by region.
Therefore, a single national goal is inappropriate. Physicians should
be encouraged to select specific specialties with shortages. This
selection could be facilitated by providing physicians information
on practice opportunities by specialties and, where appropriate, should
be offered such fiscal incentives as loan repayment opportunities.
- Increase
total enrollment in U.S. medical schools by 15 percent from their
2002 levels over the next decade.
To assure reasonable
access to care for Americans in coming years, COGME recommends that
total U.S. allopathic and osteopathic medical school enrollment be
increased by 15 percent by 2015. This step will require a combination
of increased enrollment at existing medical schools and, potentially,
the establishment of a number of new medical schools.
A modest increase
in medical school enrollment over the next decade will have only a
limited impact on the total supply of physicians in 2020 but would
provide a base for responding to future needs. Decisions on medical
school capacity need to be made now if the Nation is going to be able
to produce more U.S. medical school graduates in 2015 and beyond.
Between 1982
and 2001, the number of medical students in the U.S. increased 7 percent
while the U.S. population grew 23 percent, leading to a 13 percent
net decrease in medical school students per capita in the U.S. Between
2000 and 2020, the U.S. population is projected to increase by 18
percent while medical school capacity is scheduled to increase by
only about 4 percent, leading to a further decrease in per capita
medical students. The recommended 15 percent increase would still
leave the number of medical students per capita well below the 1980
level.
If the actual
shortage is not as significant as predicted in this report, the modest
increase of about 3,000 new U.S. graduates per year by 2015 would
allow the U.S. to reduce its current reliance on the approximately
5,200 international medical school graduates (IMGs) who enter residency
training each year. This policy would be consistent with those advocated
by many observers (Mullan 2000). Most IMGs come from countries that
have far fewer physicians per capita than the U.S. has.
Given the uncertainty inherent in long-term forecasting of supply,
demand, and need, and the cost of a major expansion in medical school
capacity, COGME does not recommend that the Nation attempt to address
all the possible shortages through a dramatic increase in medical
education capacity at the present time. Rather, COGME recommends that
the medical education community increase enrollment moderately now
and that the Nation take other steps that have the potential to reduce
future shortages. Although it may be necessary to increase enrollment
more than 15 percent in the coming years, the decision should be made
based on further study over the next few years, as discussed in recommendation
five below.
At this time,
the Council is not recommending a new Federal program to encourage
new medical schools or increased enrollment at existing medical schools.
It is hoped that the medical education community and States will respond
to the recommendations in this report and to the growing evidence
of unmet physician workforce needs.
- Phase
in an increase in the number of residency and fellowship positions
eligible for funding from Medicare to parallel the increase in U.S.
medical school graduates recommended above.
Over the next
decade, teaching hospitals will need to increase the number of training
positions to accommodate the increasing number of U.S. medical school
graduates. The current cap on the number of residents and fellows
eligible for Medicare reimbursement strongly discourages teaching
hospitals from increasing the number of residents. To encourage a
modest increase in residents, COGME recommends that the cap be increased
slowly over the next decade.
The current cap
was intended to discourage increases in the number of physicians trained
in the U.S. It was conceived and approved when there was a period
of concern with potential surpluses of physicians and when it appeared
that managed care would reduce the use of health care services. As
the Nation now looks at its physician needs for 2015 and beyond, the
far greater likelihood is a physician shortage. The Medicare policy
should be adjusted to help meet future physician needs that will be
driven in large part by the growing number of elderly covered by the
Medicare program. In light of the growth in graduates of osteopathic
schools over the past decade and the increasing number of entrants
to allopathic schools, it is important to begin to increase the GME
cap as soon as possible.
- Develop
systems to track the supply, demand, need, and distribution of physicians,
and undertake a comprehensive re-assessment within the next 4 years
to guide future decisions on medical education capacity.
Given the costs
of increasing medical education and training capacity and the uncertainty
inherent in any effort to forecast physician workforce many years
into the future, it is strongly recommended that the Nation develop
systems to track physician workforce supply, demand, need, and distribution
on a regular and consistent basis. This recommendation is especially
important in light of the many years needed to make changes in the
supply of physicians.
In addition to
ongoing tracking, COGME recommends that the Nation undertake a comprehensive
re-assessment within the next 4 years that would consider the many
factors that could have an impact on the physician workforce in the
future in greater depth than the current re-assessment. Major industries,
especially those in which changes in production require both substantial
investments and many years to implement, exemplify this point. The
leaders in these industries recognize the critical role of regular
assessments of the current and future marketplace. The current study
considers available data, but important gaps exist in these data as
well as in our understanding of physician practice patterns. In addition,
some information (e.g., retirement patterns of the baby-boom generation
of physicians) cannot be known at this time.
- Additional
specialty-specific studies are needed to better understand the physician
workforce needs and to inform the medical education community and
policy makers of the Nation’s specialty-specific needs.
On the basis of
available data, the Nation appears to have a ratio of 38 percent generalist
specialties and 62 percent non-generalist specialties. This greater
demand for non-generalist specialties is borne out by surveys of new
physicians completing residency training in the U.S. and the growing
number of reports of shortages in non-generalist specialties (Schubert
et al 2003; Miller and Lanier 2001; Schubert et al 2001; Foot et al
2000; Kim et al 2001; Suneja et al 2001; Neilson et al 2001; Angus
et al 2000; Pronovost et al 2002; Sunshine 2001; Organ 2002; Etzoni
et al 2003; Fleming et al 2003).
Experience over
the past decade has demonstrated that medical students, physicians
in training, residency programs, and teaching hospitals respond to
marketplace signals on supply and demand for different specialties.
Unfortunately, specialty-specific studies have been conducted only
sporadically in the past and often used questionable research methods
and data. The Federal Government should take a leadership role in
developing and encouraging common methodologies for specialty-specific
studies.
Providing the
medical education community and policy makers with better information
on current and future needs and on gaps in physician supply by specialty
should contribute to a specialty mix more consistent with national
needs. Accurate and timely information and data are a prerequisite
for an effective market of any type. This information should help
guide Federal policies related to the physician workforce.
- Promote
efforts to increase the productivity of physicians.
The Nation should
consider several steps to promote productivity improvements. These
steps include:
- Funding
to evaluate the effectiveness and efficiency of alternative models
of care, and practice and organizational arrangements;
- Evaluation
of specific new technologies;
- Dissemination
of information to physicians on the effectiveness of alternative
models of care, new technologies, and other strategies to improve
productivity; and
- Introduction
of reimbursement policies to support implementation of productivity
enhancements.
A modest annual
rate of increase in physician productivity would have a major long-term
impact on the number of new physicians needed by the Nation. These
steps could also encourage physicians to practice longer rather than
retire or leave medical practice, thus effectively increasing the
supply of physicians.
New technologies and improvements in existing technologies have the
potential to increase productivity, improve quality, and increase
physician satisfaction. Particularly promising is the potential for
the electronic medical record and other advances in information technology.
These advances have the potential to increase efficiency and effectiveness,
to reduce the time needed for documentation, and to speed the retrieval
of needed information. Remote patient monitoring systems, telecommunications
advances, and Internet access to the latest medical knowledge and
technologies have the potential to increase the number of patients
who can be cared for by a physician.
There are a number
of barriers to the expansion of effective new technologies. First,
many of these technologies require an enormous investment to develop
and acquire. Second, many new technologies are still to be perfected
and are evolving rapidly, leading to appropriate caution on the part
of physicians and the organizations that use them. A third barrier
for certain types of technologies is reimbursement policies. For example,
if insurers do not cover group sessions or interactions between physician
and patient over the Internet, then these approaches will be less
attractive to physicians and patients.
- Expand
programs and develop policies that:
- Address
geographic maldistribution of physicians,
- Improve
access to care for underserved populations and communities,
- Promote
appropriate specialty distribution and deployment,
- Promote
workforce diversity, and
- Support
analyses of data related to these issues.
The projected
shortage of physicians is likely to have the greatest impact on underserved
and poorer communities that have historically had the greatest difficulty
recruiting and retaining physicians. To assure access for our most
needy citizens, it will be important to maintain and expand programs
that support access to physician services by underserved populations.
In anticipation of future shortages, the number of scholarship and
loan repayment awards under the NHSC should be increased.
As indicated in
this report, shortages for non-generalists are likely. Although generalists
play a central role in underserved communities, these communities
also require access to non-generalists. Therefore, COGME recommends
that the NHSC be expanded to include non-generalist specialties. These
awards should be targeted to specialties with documented shortages
in underserved communities. Giving underserved communities access
to non-generalists should be accomplished while maintaining an emphasis
on access to primary care services. By identifying specialties experiencing
shortages for purposes of the NHSC program, the Federal Government
would also send an important message to medical students about specialties
in need.
Title VII of
the Public Health Service Act includes programs specifically designed
to encourage practice in rural and other underserved areas, to increase
the diversity of the workforce, to promote more effective medical
and interdisciplinary education, and to collect and analyze workforce
data. These programs play a critical role in helping assure access
to needed services and will be particularly important in a period
of physician shortage. COGME recommends that these programs receive
continued support.
In addition to
physician workforce programs that directly address needs in health
care delivery, policy exerts its influence through reimbursement and
regulatory actions. For example, direct and indirect GME payments
through Medicare, as well as differential payments for health care
services, have an influence on training opportunities, medical specialty
choices, and career location decisions. These influences should be
evaluated, understood, and more closely aligned with health care policy
goals.
RELATED
ISSUES OF CONCERN
Distribution
of Physicians: This analysis assesses the total number of
physicians across the country and does not assess supply, demand,
or need by State, region, or locality. It is possible for the Nation
to have enough or even more than enough physicians in aggregate and
still have significant shortages in specific communities. Although
having an adequate supply nationally will make it easier to address
distribution issues, increasing the supply will not in and of itself
address issues of maldistribution of physicians. Although this
issue is not the focus of this report, it is an issue of great importance
to the Nation and to COGME. Given the shortages predicted in this
report, it is likely that currently underserved areas will face greater
shortages in coming years if steps are not taken to ameliorate the
overall physician supply shortage. The Council intends to undertake
a review of programs and strategies to address the distribution of
physicians and to make recommendations in a future report for better
assuring an adequate distribution of the physician workforce.
U.S. Medical
School Graduates and International Medical School Graduates (IMGs):
There are two major sources of new physicians in America: graduates
of U.S. medical schools and graduates of non-U.S. medical schools.
The Nation could address the predicted future shortage by increasing
the number of physicians from one or both of these sources. This report
neither recommends an increase in the number of IMGs entering residency
training as a way to address future shortages, nor recommends a decrease
in the number of IMGs entering the U.S. It is not the purpose of this
report to assess the pros and cons of using IMGs to meet physician
workforce needs in the U.S., but it is recognized that the issues
of IMG policies, U.S. medical school capacity, and the total number
of physicians produced in the U.S. are interrelated. Clearly, if a
decision were made to reduce the reliance on IMGs, it would be necessary
to increase U.S. medical school enrollment more than recommended above
to achieve the goal of 27,000 new entrants in 2015. Conversely, an
increase in the number of IMGs entering the U.S. would reduce the
need for more U.S. medical graduates.
Impact of
Reimbursement Policies on Demand for Physician Services: Undoubtedly,
the demand for a specialty or group of specialties is affected by
reimbursement policies. Low levels of reimbursement for services can
depress demand below need. The models used in the current reassessment
of supply, demand, and need rely heavily on historical patterns of
use that have been influenced by reimbursement policies. Results of
recent surveys of residents completing training in California and
New York show that the incomes of non-generalists are significantly
higher than the income of generalists and that the gap is growing
(Nolan et al 2003a, 2003b, 2003c). Although the imbalance between
the income of generalist and non-generalist physicians is not the
focus of this report, it probably affects the measurement of demand
and need. It may be appropriate to reassess the relative levels of
reimbursement of generalists and non-generalists under current reimbursement
systems, including Medicare.
Unnecessary
Services:
Some research findings suggest that some services provided by physicians
may be of marginal benefit or even unnecessary (Weiner 1994, 1995,
2004; Fisher et al 2003a, 2003b). Drawing on recent research on staffing
ratios in prepaid group practices and the relationship between health
status and aggregate physician service utilization, the report presents
what the impact would be on demand and need if some process were found
to identify and eliminate unnecessary or ineffective services.
Some have suggested
that the number of physicians educated and trained in the U.S. should
take this into account (i.e., the Nation should produce fewer physicians
because some services are unnecessary). However, in the absence of
programs and policies that effectively identify and eliminate the
unnecessary or inappropriate services, constraining supply is likely
to lead to even greater shortages and delays in access to services
for the public at large. Such shortages and delays might occur especially
in underserved communities and among vulnerable populations.
Background
The Council on
Graduate Medical Education (COGME) was authorized by Congress in 1986
to assess physician workforce trends, training issues, and financing
policies, as well as to recommend appropriate Federal and private-sector
efforts to address identified needs. One of the most important physician
workforce issues for COGME and the Nation is the assessment of the
number, specialty, and geographical distribution of physicians that
would need to be educated and trained to assure access to quality
care for Americans. For the last decade, a series of physician workforce
policy goals held by COGME have centered around its “110/50-50”
recommendations. These goals and recommendations should be revised.
First articulated
in its Third Report, Improving Access to Health Care Through Physician
Workforce Reform: Directions for the 21st Century (1992), the
110/50-50 recommendations called for reducing the number of physicians
entering residency training from what was then 140 percent to 110
percent of the number of graduates from allopathic and osteopathic
medical schools in the U.S. in 1993. Conceptually, the 110 percent
would be sufficient to ensure that all U.S. medical school graduates
would be able to enter graduate medical training, as well as IMGs
equal in number to 10 percent of the U.S. graduates. The Third
Report called for increasing the percentage of graduates who complete
training and enter practice as generalists from the level then at
30 percent to at least 50 percent. COGME’s Eighth Report,
Patient Care Physician Supply and Requirements: Testing COGME Recommendations
(1996), provided underlying physician supply and requirements projections
that tended to support the reasonableness of the recommendations.
COGME’s Fourteenth Report, COGME Physician Workforce Policies:
Recent Developments and Remaining Challenges in Meeting National Goals
(1999), in calculating the progress made toward the COGME goals, found
that as of 1997 and 1998, the Nation’s first-year residents amounted
to approximately 129 percent of the number of graduates from allopathic
and osteopathic medical schools in the U.S. in 1993. This report also
found that it would be necessary to reduce the number of first-year
residents by about 3,400 to reach the 110 percent goal set by COGME
in 1992.
The Fourteenth
Report identified several recent developments that were likely
to affect the supply or demand, or both, for physician services. These
developments include: the evolving nature of managed care, the growing
supply of non-physician clinicians, and the growing representation
of women in medicine. In this 1999 report, the Council stated its
intention of re-assessing the appropriateness of its 110/50-50 recommendations
in light of recent developments.
Supply
of Physicians, 2000-2020
OVERVIEW
OF METHODOLOGY: BASELINE MODEL AND FACTORS AFFECTING FUTURE SUPPLY
The forecast of
physician supply in the U.S. between 2000 and 2020 is based on the
Physician Supply Model (PSM). This model, developed and maintained
by the Bureau of Health Professions (BHPr), HRSA, DHHS, produces projections
of the supply of physicians by type (Medical Doctor [MD] and Doctor
of Osteopathy [DO]) and specialty for 1995 through 2040. For the purposes
of this report, the years of interest are 2000 through 2020, and the
specialty groups of interest are generalists and non-generalists.
This section presents the total supply forecasts and factors affecting
the overall supply of physicians in the U.S. Projections for generalists
and non-generalists appear in Section V, “Physician Supply, Demand,
and Need.”
The unit of analysis
for the assessment is a full-time equivalent (FTE) active physician.
This unit includes all physicians active in medicine, regardless of
whether they are providing patient care. It is estimated that about
6 percent of active physicians in 2000 were not providing patient
care. Many of these physicians were involved in teaching, administration,
and research (Pasko and Seidman 2002). Since one goal of the project
is to assess the number of physicians that would need to be produced
to meet future needs, it is necessary to include non-patient care
physicians as well as active physicians in the projections. To take
into account the fact that some physicians practice less than full-time,
for this analysis, supply, demand, and need are calculated in terms
of full-time equivalents; that is, two physicians working half-time
are equal to one FTE.
The calculation
of future physician supply begins with the number of physicians entering
residency training. The methodology includes the following steps:
- The PSM begins
with the active base year physicians by type and post-medical school
graduate year (PGY).
For each forecast
year:
- The
base year physicians are aged, and age-specific death and retirement
rates are applied.
- The physicians
are summed over all ages to calculate the base physicians by type
and PGY.
- Specialty distributions
are applied by type and PGY.
- Activity distributions
are applied by type, specialty, and PGY.
- New entrants
by year (2001 through 2020) of each type of physician indicated
below, using the data described, are tallied:
- United
States Medical School Graduates (USMGs): New graduates from U.S.
medical schools and percentage of females by year;
- Canadian
Medical School Graduates (CMGs): New graduates from Canadian medical
schools and percentage of females by year;
- IMGs:
International medical school graduates who are GME entrants and
percentage of females by year; IMGs who are non-GME entrants and
percentage of females by year;
- New entrants
are aged over the period 2000 through 2020 for each and the appropriate
age and type-specific death and retirement rates are applied;
- Specialty distributions
are those applied by type and PGY to new entrants;
- Activity distributions
are those applied by type, specialty, and PGY to new entrants;
- Forecasts of
base year physicians and new entrant physicians by type, PGY, specialty,
and activity are summed over PGY to produce final forecasts (Bannister
et al 2001).
The forecast totals
are then converted to FTEs. Table 1 presents the results of the baseline
supply model.
The supply of
physicians is projected to grow by some 190,000 FTEs (24 percent)
between 2000 and 2020.4 Over the same time period, the
U.S. Census Bureau projects an 18 percent growth in the U.S. population,
yielding a net 5 percent growth in the physician-to-population ratio.
As indicated in Table 1, the supply expressed as FTEs per capita peaks
around 2015, and then begins to fall, as the rate of population growth
begins to outstrip the rate of growth in the supply of physician FTEs.
The data used
in the PSM for this project were derived from the following sources:
- Current
supply and characteristics:
- American
Medical Association (AMA) Physician Masterfile
- American
Osteopathic Association (AOA) Masterfile
- Distribution
by age, gender, and IMG status: AMA Physician Masterfile
- New U.S.
graduates 2000 by age and gender: Association of American Medical
Colleges (AAMC), AMA, and AOA Masterfile
- New CMGs
and IMGs: AMA Graduate Medical Education data
- Retirements,
deaths, and departures:
Analysis of AMA Physician Masterfile patterns 1990 through 1995
Given this methodology,
it is clear that the model takes a number of basic factors into account
in making projections. These factors include:
- The overall
number of new entrants into the physician workforce and the source
of the new entrants (i.e., U.S. medical schools or abroad);
- The gender
distribution of the current physician supply and of new entrants
and its effect on the relative number of hours spent in professional
activities (to calculate FTEs);
- The age distribution
of the current physician supply;
- Retirement,
death, and other separation rates of the current physician supply;
- The specialty
distribution of the current physician supply and the specialty choices
of new entrants; and
- The rates of
different types of professional activities (e.g., patient care,
teaching, and research) of the current physician supply.
These factors
are included in the supply projection model through the use of historical
rates and trends derived from both previous research and the data
sources listed above. Below, these factors are discussed in more detail,
and any assumptions made in the baseline model are revealed.
New
Entrants
Number of U.S.
medical school graduates: The baseline model assumes that the
number of U.S. allopathic medical school graduates will remain essentially
constant through 2020 at 16,000 per year. It also assumes that osteopathic
graduates will continue to increase from about 2,300 in 2000 to 3,000
in 2009, and then stabilize at that level. It further assumes that
the number of Canadian entrants into the U.S. health system will slowly
rise from 191 in 2000 to 247 in 2020. Thus, for most of the period,
it is assumed that there will be about 19,000 new USMG, CMG, and DO
entrants each year. Table 2 presents the estimated entrants into the
health care system between 2000 and 2020 as used in the model. Figure
1 shows the number of allopathic and osteopathic graduates over the
past 20 years and the forecast for 2001 through 2020. Figure 2 depicts
the extent to which the growth of the U.S. population has exceeded
the growth in the number of students enrolled in U.S. medical schools.
The medical school
community has discussed the possibility of new medical schools and
increases in enrollment at existing medical schools (e.g., see Cooper
2003; Mullan 2003; Wood 2003; Hallock et al 2003; as well as Mullan
2000). Several new schools are in various stages of development or
accreditation (e.g., in Florida, Arizona, and Texas).
[D]
[D]
Several additional
new schools are being discussed in other locations, but this development
is likely to add only a modest number of new physicians to the supply
over the next several years. This is the case because of the time
it takes before new medical schools produce practicing physicians,
as well as the modest nature of current development efforts. This
expansion is not factored into any models described in this analysis.
Moreover, several other important issues related to the expansion
of medical education in the U.S. would have to be addressed before
any large-scale expansion could occur.
Number of international
medical school graduates: The baseline model assumes 5,200 new
IMG entrants per year based on historical trends. An analysis of AMA
GME data and the AMA Physician Masterfile indicates that this is close
to the experience throughout the 1990s. Given recent political developments
(i.e., the tragic events of September 11, 2001; increased scrutiny
of immigrants domestically; Operation Iraqi Freedom; as well as a
host of others), it is possible that future immigration policies will
limit the flow of IMGs into the U.S. in coming years.
It is certainly
conceivable that the current inflow could decrease in the near future.
Any decrease in the number of IMGs entering the physician supply without
a simultaneous increase of USMG, CMG, and DO entrants would lead to
fewer physicians than are currently projected. At the same time, it
is also conceivable that the number of IMGs could increase because
of the recent upswing in U.S. citizens attending medical schools abroad
(Salsberg and Forte 2002). These potential changes are not factored
into any models described in this analysis.
Women in Medicine
Women have made
great strides in medicine over the past 20 years, nearly tripling
their representation in the profession. Currently making up about
25 percent of the physician workforce, women will continue to become
a larger part of the workforce because they currently make up nearly
50 percent of the students enrolled in U.S. medical schools (Salsberg
and Forte 2002).
A number of studies
have documented that women work fewer hours over the course of their
professional work life than men (Kletke, Marder, and Silberger 1990;
Bobula 1980; Martin et al 1988; Cooper 1994; Australian Medical Workforce
Advisory Committee/Australian Institute of Health and Welfare [AMWAC/AHIW]
1996, 1998; Sullivan and Buske 1998; Forte and Salsberg 1999). This
phenomenon may reflect time taken for child rearing, for providing
care for elderly parents or other relatives, and for taking care of
other family concerns. The baseline model accounts for the gender
difference as it is based on historical work patterns. As Table 3
shows, the FTE-to-physician ratio decreases over time. This decrease
is indicative of the increasing representation of women in the physician
workforce as well as the aging of the workforce.
Aging of the
Physician Workforce
Like the rest
of the U.S. population, physicians, as a group, are growing older.
In fact, between 1982 and 2001, the proportion of physicians aged
65 and older increased from 8 percent to 11 percent. In 2001, more
than 84,000 practicing physicians were 65 years of age or older, another
118,000 between 55 and 64 will reach 65 by 2011, and another 203,000
between 45 and 54 will reach 65 by 2021 (Figure 3). The baseline model
accounts for these changes by applying historical age-specific activity
rates to the supply of physicians each year, as well as by adjusting
for this in the FTE-to-physician ratios used to calculate FTEs. If
these activity rates do change in the future, the projections of the
baseline model will either under- or overestimate the actual supply
of physicians depending on the direction of the change.
[D]
Separation
From the Physician Workforce
In some ways,
separation from the physician workforce is related to age. As a physician
ages, he is more likely to leave practice for one reason or another,
for example, retirement or death. The baseline model assumes that
physicians in the future will separate from the workforce at the same
age-specific rates as they have historically. In other words, physicians
in the future will time their retirements as physicians have in the
past. With the aging of the physician population, a larger and larger
proportion of the physician workforce will be reaching the traditional
age of retirement in the near future. This larger proportion is reflected
in the baseline model by an increase in the net retirement rate from
1.2 percent in 2000 to 1.9 percent in 2019, a 58 percent increase.
There is no way
to know with certainty the actual retirement patterns of physicians
in future years. Earlier retirement of the baby-boom generation of
physicians than of previous generations would significantly reduce
the supply of physicians in 2020. On the other hand, if physicians
are working fewer hours per week because of changing lifestyle choices,
they may stay in practice for a longer period of time, not having
as much chance to burn out or become dissatisfied for some other reason.
This phenomenon might lead to an increase in the supply of physicians
in 2020.
In addition,
since there is no reason to expect the other sources of separation
(e.g., death) to change, they are also held at their historical levels.
Specialty Distribution
and Choices
The issue of specialty
distribution and choice has less to do with the overall supply of
physicians than with the types of services provided by physicians.
The specific specialty a physician practices has implications for
the types of services provided. As mentioned previously, for the purposes
of this re-assessment, discussion and consideration of specialty were
limited to a generalist and non-generalist distinction. The baseline
model assumes that physicians will choose specialties according to
their historical patterns of specialty choice; that is, about 68 percent
of physicians will eventually practice in non-generalist specialties.
The model also assumes that physicians will have made their final
specialty choices by the tenth year after the start of their graduate
medical training.
There have been
a number of attempts at understanding the reasons behind physicians’
specialty choices (Hay 1991; Hurley 1991; Nicholson 2002; Puccio et
al 2002; Newton and Grayson 2003; Dorsey et al 2003). The factors
most often cited to explain variation in specialty choice include
expected income, intellectual content of the specialty, research opportunities
in the specialty, prestige of the specialty, gender and race/ethnicity
of the physician, family considerations, and others. The dynamics
of specialty choice are beyond the scope of this re-assessment. Thus,
as noted above, unless otherwise stated, historical rates of specialty
choice by age and location of education (USMG or IMG) are employed
in the models presented in this paper.
Activity Rates
Being a physician
involves a variety of activities, including patient care, medical
teaching, medical research, and other medical activities. Physicians,
however, are not limited to those types of activities. The rate at
which the supply of physicians in the Nation participates in activities
within their field of expertise (i.e., medicine) and activities outside
the realm of medicine directly affects the number of available physicians.
The baseline model assumes that activity rates will remain at their
historical levels. If activities outside the scope of what are currently
considered the professional activities of a physician (e.g., physicians
working as financial analysts) become more attractive to physicians,
the effective supply of physicians in the U.S. would decrease.
Moreover, changes
in the distribution of activities in which a physician participates
could also have effects on the supply of physicians. For example,
the average physician typically spends the most amount of her time
in patient care. If more physicians devoted more time to research,
the supply of physicians providing patient care services would decrease.
Dynamics within the professional activities of physicians are beyond
the scope of this re-assessment. In fact, since the models project
active physicians, distinctions between types of professional activity
are not taken into account. Again, such distinctions only become important
if there is an increase in the rate of participation in an activity
that is associated with significantly different practice patterns.
ALTERNATIVE
SUPPLY SCENARIOS AND ASSUMPTIONS
The baseline models
used in this report are based on historical data. A number of other
scenarios were modeled and sensitivity analyses performed to assess
the impact of potential changes in key factors influencing the supply
of physicians. Each alternative scenario was built to represent the
impact of changes to one key factor affecting the future supply of
physicians in the U.S., or two factors in the case of hybrid models.
The scenarios developed for this report are only a sampling of the
myriad possibilities that could occur over the next two decades in
the physician workforce. The following discussion presents the background
and the results of the projections generated for each scenario.
Alternative
Scenario One: Lifestyle Changes
A number of observers
of the physician workforce have noted the desire of many, or even
most, new physicians to balance professional and personal activities,
i.e., to have a more controllable lifestyle (Schwartz et al 1989;
Schwartz et al 1990; Jarecky et al 1991; Bland and Isaacs, 2002; Gelfand
et al 2002). These observers have also noted that the phenomena described
above of women working fewer hours is part of a larger generational
phenomenon, affecting not only physicians, but also other professionals
as well (Bond et al 1998; Lang 2000; Gutner 2002). If the new generation
of physicians prefers to work fewer professional hours, the FTE physician
supply in the U.S. will be reduced.
By some indications,
older physicians are reducing the hours they work (Cooper 2002b).
For example, in New York, a recent survey finds that a significant
proportion of physicians expect to reduce their hours worked in the
year ahead (Salsberg et al forthcoming). If older physicians are also
reducing their hours, it may lead to a decrease in total physician
FTEs similar to that of the new generation of physicians.
To estimate how
these lifestyle changes may affect the supply of physicians in the
U.S. in the future, it was assumed that by 2020, physicians would
work 10 percent fewer hours on average than presumed in the baseline
model.5 Table 4 presents the results of the scenario.
Under Alternative
Scenario One, the supply of physicians is projected to grow by some
105,000 FTEs (13 percent) between 2000 and 2020 compared to the projected
increase of 190,000 FTEs (24 percent) under the baseline projection.
Thus, if lifestyle changes lead to a decrease in the hours worked
by active physicians by 10 percent, the number of FTE physicians in
2020 would be 86,000 less than the baseline projections would suggest.
The U.S. Census Bureau projects an 18 percent growth in the U.S. population,
yielding a net 4 percent drop in the FTE physician-to-population ratio.
It is important to note that according to this model, the FTE physician-to-population
ratio peaks in 2005 compared to a peak in 2015 in the baseline model.
Clearly, the lifestyle changes described above would limit the supply
of physicians in the U.S.
Sensitivity
Analysis: Alternative Scenario One
For a better understanding
of the breadth of influence that lifestyle changes might have on the
supply of physicians, a simple sensitivity analysis was performed
by changing the assumption of how large the effect of lifestyle changes
(i.e., the reduction in hours worked among physicians) would be by
2020. On the low-effect end, it was assumed that lifestyle changes
would decrease hours worked by 5 percent by 2020; whereas on the high-effect
end, it was assumed that lifestyle changes would decrease hours worked
by 20 percent by 2020. Table 5 presents the results of this analysis.
A decrease of
5 percent in the number of hours worked by physicians by 2020 is projected
to result in an increase of about 145,000 physician FTEs during the
time period and, in every practical sense, a stable FTE physician-to-population
ratio. On the other hand, a decrease of 20 percent in the number of
hours worked by physicians by 2020 seriously depletes the physician
supply in absolute as well as relative terms. This is the first projection
in which the absolute number of FTEs peaks before 2020. Clearly, the
assumption about future lifestyle changes could have important implications
for the projected supply of physicians in the U.S. in 2020.
Alternative
Scenario Two: Productivity Changes
Another important
factor that can influence the available supply of physicians in the
U.S. is physician productivity. Productivity, in this instance, is
defined as output divided by time spent. Although the lifestyle changes
above assumed a constant level of productivity and a decline in time
spent practicing, here the focus is changes occurring in medical practice
that allow physicians to practice more efficiently. New medical technologies,
particularly in the area of information systems, could lead to an
increase in physician productivity. For example, the electronic medical
record could allow physicians to quickly, easily, and accurately access
and assess all the necessary information on a patient’s history
instead of having to order the file be sent to him, and then shuffling
through the paper file. Estimates of the potential productivity gains
through the use of new technologies or implementation of already existing
technologies are widely variable (Blumenthal 2002; Masys 2002; Goldsmith
et al 2003). A recent study suggests a potential gain of 20 percent
through the use of technology (Corrigan 2003).
To determine the
effect of increased productivity on the supply of physicians, it was
assumed that the physician workforce would be 20 percent more productive
by 2020.6 Table 6 presents the results of the scenario.
Under Alternative
Scenario Two, the supply of physicians is projected to grow by over
425,000 FTEs (55 percent) between 2000 and 2020 compared to 190,000
(24 percent) under the baseline projection. Thus, if physician productivity
increases by 20 percent by 2020, the number of FTE physicians in 2020
would be 235,000 more than the baseline projections would suggest.
The U.S. Census Bureau projects an 18 percent growth in the U.S. population
between 2000 and 2020, yielding a net 31 percent increase in the FTE
physician-to-population ratio. It is important to note that according
to this model, the FTE physician-to-population ratio does not peak
in the time period under investigation compared to a peak in 2015
in the baseline model. Clearly, productivity changes as described
above could increase the supply of physicians in the U.S.
Sensitivity
Analysis: Alternative Scenario Two
On the low-effect
end, it was assumed that physician productivity would increase by
10 percent; whereas on the high-effect end, it was assumed that physician
productivity would increase by 30 percent. Table 7 presents the results
of this analysis.
A physician productivity
increase of 10 percent by 2020 results in an increase of over 105,000
physician FTEs beyond the baseline projections of physicians. On the
other hand, an increase of 30 percent in physician productivity leads
to a substantially higher projected physician supply. It is difficult
to believe that gains of this magnitude could be realized, which suggests
that further study of the impact of physician productivity enhancements
is in order. Nonetheless, it is clear that the particular assumptions
about potential productivity gains have important implications for
the projected supply of physicians in the U.S. in 2020.
Alternative
Scenario Three: Hybrid Lifestyle/Productivity Changes
Combining the
previous two alternative scenarios reveals a more complete picture.
This scenario portrays an environment in which physicians are working
more productively, but also are working fewer hours, having more time
to spend on other pursuits, such as their families. Working from the
previous scenarios, the relevant assumptions here include a reduction
of 10 percent in hours worked, coupled with an increase in productivity
of 20 percent between 2000 and 2020.7 Table 8 presents
the projections derived from this scenario.
A consideration
of the scenario with a similar change will project a growth in this
scenario in which the supply of physicians will grow by almost 300,000
FTEs (38 percent) between 2000 and 2020 compared to 190,000 (24 percent)
under the baseline projection. Thus, if both physician lifestyles
change and productivity increases by 2020, the number of FTE physicians
in 2020 would be 105,000 more than the baseline projections would
suggest.
Sensitivity
Analysis: Alternative Scenario Three
For a determination
of the effects of a combination of alternative assumptions regarding
lifestyle changes and productivity enhancements, a sensitivity analysis
was developed. On the low-effect end, it was assumed lifestyle and
productivity changes would be small: a 5 percent lifestyle effect
(fewer hours worked) and a 10 percent productivity increase. On the
high-effect end, it was assumed that lifestyle and productivity changes
would be great: a 20 percent lifestyle effect (fewer hours worked)
and a 35 percent productivity increase. Table 9 presents the results
of this analysis.
A physician productivity
increase of 10 percent, coupled with a 5 percent reduction in hours
worked because of lifestyle changes by 2020, results in an increase
of about 50,000 physician FTEs beyond the baseline projections of
physicians. On the other hand, an increase of 35 percent in physician
productivity, coupled with a 20 percent reduction in hours worked
by 2020, leads to 166,000 more FTE physicians than those projected
by the baseline model.
CONCLUSIONS:
SUPPLY OF PHYSICIANS IN THE U.S., 2000-2020
Projections of
the supply of physicians in the U.S. between 2000 and 2020 forecast
that the supply of physicians will continue to grow in absolute terms
throughout the period. Although the magnitude of the projected growth
varies considerably, it is likely that the supply of physicians will
grow between 100,000 and 300,000 FTE physicians during the time period,
depending on the particular assumptions made about lifestyle changes
and potential productivity gains in the future. The baseline physician
supply projections suggest that by 2020 there will be 971,817 physicians
practicing in the U.S. It is likely, however, that changes in physician
lifestyle choices and in their level of productivity will have an
effect on that growth. It is conceivable that these changes will have
an overall effect of increasing the physician supply beyond the baseline
projection level. The magnitude of that effect is unclear at this
time, but it will probably be modest. Thus, it is also likely that
the supply of physicians will fall somewhere in the range of 972,000
and 1,077,000 physicians.
Further, analysis
of the model results and factors affecting the future supply of physicians
suggest a number of areas of targeted research, including: the effectiveness
of current efforts to increase the medical education capacity in the
U.S.; changes in the rate of retirement among physicians and their
ramifications; generational lifestyle changes and their potential
effects on the physician workforce; changes in activity rates among
physicians in terms of professional activities within and outside
of medicine; productivity enhancements among the physician workforce;
and issues related to the selection of specialties by young physicians
and changes in historical specialty-specific rates of selection.
Future
Demand for Physicians, 2000-2020
OVERVIEW
OF METHODOLOGY: BASELINE MODEL AND FACTORS AFFECTING FUTURE DEMAND
The baseline forecast
of demand for physicians in the U.S. between 2000 and 2020 is based
on the Federal Physician Demand Model (PDM). This model, developed
and maintained by BHPr, HRSA, DHHS, produces projections of full-time
physician equivalent demand by specialty for 1995 through 2020. For
the purposes of this report, the years of interest are 2000 through
2020, and the specialty groups of interest are generalists and non-generalists.
This section presents forecasts of the total demand for physicians
and factors affecting the overall demand for physicians in the U.S.
Projections of demand for generalists and non-generalists appear in
Section V.
The model’s
approach is to assign populations to specific delivery settings and
then to choose a staffing configuration for each setting. First, the
model defines populations according to gender, age (groups include:
0-4, 5-17, 18-44, 45-64, 65-74, 75-84, 85 and older), location (urban
or rural), and insurance status. From these characteristics, a matrix
of delivery settings is created. The model then distributes the U.S.
population across these delivery settings. (Figure 4 shows a simplified
matrix of these delivery settings.) Then, the model calculates the
number of physicians necessary to meet the requirements of those populations
based on how they are distributed across the delivery settings. These
calculations are based on historical staffing patterns for the delivery
settings. The data used to compile these historical trends are derived
from the National Health Interview Survey (NHIS) and the National
Ambulatory Medical Care Survey (NAMCS). The population projections
used in the model are based on U.S. Census Bureau middle series estimates
of population growth between 2000 and 2020 (Bannister et al 2001).
The assumption most important to the accuracy of the model is that
the utilization rates of the various populations included in the model
and the staffing levels at the various delivery settings will remain
at their historical levels (i.e., levels recorded during the early
to mid-1990s) and constant over time through 2020.8 A discussion
of the effects of challenges to this assumption is included in the
alternative scenarios section below.
*HMO = Health Maintenance
Organization
†IPA = Individual Practice Association
‡FFS = Fee for Service
Conceptually,
then, demand is being equated with use of physician services under
a specific set of circumstances. Demand is not conceptualized in this
model as what a population with certain characteristics might desire
in terms of physicians, access to physicians, or physician services.
In fact, in the absence of coercion, demand as defined in the model
will consistently be lower than demand defined as population desire
for services. This is an important conceptualization in terms of how
to interpret the results of the forecasts presented below and in terms
of how need is conceptualized in this report (for a discussion of
need, see Section IV).
Table 10 presents
the baseline model results.
The demand for
physicians is projected to grow by almost 210,000 FTEs (26 percent)
between 2000 and 2020. Over the same time period, the U.S. Census
Bureau projects an 18 percent growth in the U.S. population, yielding
a net 7 percent growth in the demand for physicians as expressed in
an FTE physician-to-population ratio. Unlike the supply of physicians,
the demand for physicians is not projected to peak during the time
period under investigation. Relative to the baseline supply projections,
demand is projected to grow more quickly; thus, a shortage is projected.
However, this is only one projection. What happens if other factors
that affect demand for physicians are taken into account?
ALTERNATIVE
DEMAND SCENARIOS AND ASSUMPTIONS
The first alternative
scenario entails an accounting of the effect that economic growth
has on demand for physicians. The second alternative scenario modifies
the assumptions that the age-specific utilization rates are constant,
suggesting that these rates are changing for all age groups, but most
important for populations over 45 years of age. The final alternative
comes out of the work begun by John Wennberg and colleagues (Wennberg
and Cooper 1999) and most recently exemplified in Fisher et al’s
(2003a, 2003b) just published multi-article research that suggests
actual demand for services is much lower than current rates of utilization
because of unnecessary service provision. The idea of unnecessary
services is also related to work that suggests appropriate levels
of demand for physician services are best exemplified in settings
where earnest utilization review processes have been implemented.
This line of reasoning is associated with Weiner’s (1994, 1995)
work in the mid-1990s examining HMO staffing levels and recent update
examining large prepaid group practices (Weiner 2004).
For a more comprehensive
assortment of physician demand projections, several scenarios are
presented based on each perspective listed above. Each alternative
scenario was built to represent the manipulation of one major factor
affecting the future demand of physicians in the U.S., or two factors
in the case of hybrid models. Below, the reasoning behind, and the
results of, the projections generated are presented. For a better
understanding of the ramifications of the assumptions accompanying
each alternative scenario, sensitivity analyses were also performed.
Alternative
Scenario One: Economic Factor
The first alternative
scenario works from the perspective currently championed by Cooper
et al (2002, 2003) (past proponents include Schwartz and colleagues
in the late 1980s and early 1990s, and Roehrig and Eisenstein in 1999).
This perspective argues that four major factors drive demand for physician
services: economic expansion, population growth, work effort of physicians,
and services provided by other practitioners (i.e., non-physician
clinicians). Cooper and colleagues suggest that the most important
of the four factors affecting physician demand is economic expansion.
They find a consistent correlation between the supply of physicians
and economic growth. However, Cooper and colleagues suggest that the
relationship is complex. Economic growth induces growth in demand
for health services, causing a rise in health care spending. This
growth in health care spending, in turn, leads to a growth in the
health care workforce, of which physicians are an important part.
This perspective
is certainly not without opponents (e.g., Grumbach 2002; Barer 2002;
Weiner 2002). It is easy to believe that in an environment of increasing
health care costs and declining budgets, resistance to this sort of
perspective is going to arise. However, only one published research
article has presented data that challenge Cooper and colleagues’
findings (Anderson et al 2003). As with any perspective, though, proponents
have never claimed that the theory holds under all conditions and
assumptions. Nonetheless, the jury may still be out on this perspective,
but the evidence supporting it is compelling enough to generate a
scenario based on some of its principles.
The baseline model
used in this report to predict future demand for services takes each
of the factors identified by Cooper and colleagues into account except
for a consideration of economic expansion. All data necessary to incorporate
the suggested causal pathway between economic expansion and demand
for physician services were unavailable to construct an alternative
scenario. Thus, the causal process was greatly simplified and the
findings of Cooper et al (2002) that the use of physician services
increases approximately 0.75 percent for every 1.00 percent increase
in a Nation’s gross domestic product (GDP) were employed. The
scenario further assumed that GDP per capita will rise about 1.0 percent
per year between 2000 and 2020 (Heffler et al 2003). Figure 5 shows
the historical relationship between the growth of GDP and the supply
of physicians in the U.S. Table 11 presents the projections of physician
demand after incorporation of the economic factor.
[D]
Source:
Cooper 2002a.
Under Alternative
Scenario One, the demand for physicians is projected to grow by over
340,000 FTEs (44 percent) between 2000 and 2020. This scenario compares
to a growth of 206,000 FTEs (26 percent) under the baseline demand
scenario. Over the same time period, the U.S. Census Bureau projects
an 18 percent growth in the U.S. population, yielding a net 22 percent
growth in the demand for physicians as expressed in an FTE physician-to-population
ratio. The 22 percent increase in demand for physicians under this
scenario far exceeds that (7 percent) predicted by the baseline model.
It is interesting to note that the absolute growth in physician demand
predicted under this scenario between 2000 and 2010 (19 percent) closely
resembles that predicted by the BLS over the same time period (18
percent) and forecasts made by Cooper and colleagues (2002).
Sensitivity
Analysis: Alternative Scenario One
Even though the
predictions generated under the current alternative scenario are similar
to other attempts to forecast physician demand in the future, it is
important to understand how the results of the model might be different
under an alternative set of assumptions about economic growth. Cooper
et al (2002) point out that the assumption of the level of economic
growth is a particularly important one for predictions incorporating
this perspective. For a test of the effects of different assumptions
about the rate of growth of the economy, a simple sensitivity analysis
was performed. On the low-effect end, it was assumed that the U.S.
economy would grow 0.5 percent annually between 2000 and 2020; whereas
on the high-effect end, it was assumed that the U.S. economy would
grow 2.0 percent annually. Table 12 presents the results of this analysis.
Although the levels
of economic growth experienced in the late 1990s in the U.S. are unlikely
to occur for any sustained length of time, it is just as unlikely
that the economy would decline for any extended period of time. The
levels of economic growth considered in these analyses appear quite
reasonable. On the conservative side (a sustained slow-growing economy:
0.5 percent annual GDP growth), demand for physicians will increase
by 270,000 physicians between 2000 and 2020 (35 percent). On the other
hand, a sustained 2 percent annual growth in the economy (a rate much
closer to that in the early 1990s and to what has been projected over
the next decade [Heffler et al 2003]) translates into a much more
substantial growth of close to 400,000 FTE physicians between 2000
and 2020 (64 percent). The effect of economic growth is substantial,
regardless of the level of economic growth assumed. Whether economic
growth is the cause of physician demand growth is impossible to determine
within the scope of this report. But even if they are only correlated,
the end result will be the same: economic growth seems to coincide
with growth in the demand for physicians.
Alternative
Scenario Two: Changes in Age-Specific Utilization Rates
One assumption
of the baseline model is that historical utilization rates will remain
constant over time. With respect to age, independent investigation
shows that utilization rates are changing. Most observers are familiar
with findings suggesting that as the population grows older, overall
utilization will increase because utilization rates increase with
age. As indicated in Figure 6, the number of Americans over 65 years
of age is increasing and will increase significantly in the coming
years. Figure 7 documents the increased use of inpatient services
by age. Clearly, the aging of the population is leading to an increase
in demand for services in America. However, if one examines utilization
rates over time, especially physician office visits, it becomes evident
that utilization rates by age group are changing.
[D]
Source:
U.S. Census Bureau Population Projections.
[D]
Analysis of the
National Ambulatory Medical Care Survey (NAMCS) data from 1980, 1990,
and 2000 on visits to physician offices by age group (Figure 8) indicates
that the number of physician visits per capita for age groups over
45 years of age have been increasing over the past few decades. There
is reason to believe that this trend will continue and may even accelerate
as the baby-boom generation ages. The baby-boom generation has grown
up with high expectations for health care and has experienced higher
utilization rates than those of previous generations. In addition,
as the baby-boomers age, many, but certainly not all, will have disposable
income that they may choose to spend on health care (Knickman et al
2003).
[D]
Between 1980
and 2000, crude per capita visits to physician offices increased from
2.4 to 2.9. However, this increase was not evenly distributed across
age groups. The largest gain was experienced among persons 75 to 84
years of age, increasing from 3.5 visits to 6.3 visits annually. All
other groups above age 45 experienced gains as well, except the 85
years of age and above group. It turns out, however, that even though
there was a global increase in utilization, for persons in the 15-
to 24-year-old and the 25- to 34-year- old age groups, utilization
rates declined between 1980 and 2000. Further, the more recent changes
in utilization (i.e., 1990 compared to 2000) demonstrated a uniform
set of increases and declines, with all groups below age 45 having
experienced declines in annual per capita visits to physician offices
and those age 45 and above having experienced increases in annual
per capita physician office visit rates.
One explanation
for the rise in use among those over 45 years of age is that it reflects
the investment of many billions of dollars in medical research interventions.
These interventions may well be leading to increased demand for medical
services.
For the observed
changes in age-specific utilization rates to be taken into account,
a scenario was constructed that represented a continuation of the
observed 1990 through 2000 trends between 2000 and 2010 and between
2010 and 2020.10 Under this scenario, not only is the effect
of the aging of the population considered, but also the trends in
age-specific utilization rates (declining among the younger population
and increasing among the older population) are also taken into account.
Table 13 presents the projections made based on this alternative scenario.
Under Alternative
Scenario Two, the demand for physicians is projected to grow by close
to 330,000 FTEs (42 percent) between 2000 and 2020 in comparison with
the 206,000 FTE growth (26 percent) predicted by the baseline model.
Over the same time period, the U.S. Census Bureau projects an 18 percent
growth in the U.S. population, yielding a net 20 percent growth in
the demand for physicians as expressed in an FTE physician-to-population
ratio. It is important to observe the explosion of demand for physicians
in the years after 2010, when the combined effect of an aging population
and the increased utilization rates of the above age 45 group are
evident. The 20 percent increase in demand for physicians under this
scenario far exceeds that (7 percent) predicted by the baseline model.
It is interesting to note that the absolute growth in physician demand
predicted under this scenario between 2000 and 2010 (17 percent) closely
resembles the results of the previous alternative scenario that represented
an attempt to account for the effect of economic expansion on physician
demand (19 percent). Further, as mentioned above, other predictions
of physician demand unrelated to the current project are also consistent
with the predictions of this alternative scenario.
Sensitivity
Analysis: Alternative Scenario Two
The predictions
generated under the current alternative scenario are similar to other
attempts to forecast physician demand in the future. Despite this
fact, it is important to understand how the results of the model might
be different under an alternative set of assumptions about the change
in age-specific utilization rates, especially in light of the explosive
nature of the combined effects of an aging population and increased
utilization among the older population. For a test of the effects
of different magnitudes of change in age-specific physician utilization
rates, a simple sensitivity analysis was performed. On the one hand,
it was assumed that the age-specific utilization rates would change
at half the rate they changed between 1990 and 2000. On the other
hand, it was assumed that the age-specific utilization rates would
change at one and a half times the rate they changed between 1990
and 2000.11 Table 14 presents the results of this analysis.
The levels at
which age-specific rates of utilization will grow in the future will
have serious implications for the demand for physicians in the U.S.
As is evident from the alternative projections of the high and low
scenarios of utilization rate growth, the range of the effect is approximately
220,000 FTE physicians. In the low-growth scenario, demand for physicians
grows to just over 1 million FTEs in 2020 (31 percent), a figure significantly
lower than predicted in the initial projections taking into account
age-specific utilization rate changes. Again, it is important to observe
that almost 75 percent of the increase occurs between 2010 and 2020,
testament to the combined effect mentioned above. On the other hand,
if the changes in the utilization rates accelerate as is the case
in the high-growth scenario, the demand for physicians may increase
to almost 1.25 million FTE physicians, or 381 FTE physicians per 100,000
population. Since the aging of the U.S. population cannot be reversed
at this point, the effects of changes to the age-specific physician
utilization rates are extremely important. Although this alternative
scenario projects a wide range of potential effects associated with
these changes, it is clear that closer examination and future research
should be targeted at understanding the dynamics and trajectories
of these rates.
Alternative
Scenario Three: Elimination of Unnecessary Services/Increased Utilization
Review
The first two
alternative scenarios examined factors that were either inadequately
taken into account or ignored completely in the baseline projections.
However, the issue in the third alternative scenario deals with a
different kind of problem in the baseline projections. This imperfection
is that of the model, which too closely resembles reality, including
not only the beneficial qualities of the current health care delivery
system, but also its faults. In particular, unnecessary services,
according to some, are common in the current health care delivery
system.
There are a number
of reasons to believe some current use is unnecessary or only marginally
beneficial. Possible causes include: poor physician performance due
to an oversupply of physicians in a geographical area; the complexities
of current treatment modalities and the inability of individual physicians
to sort through them competently enough to understand which test or
treatment is appropriate; advertisements targeted toward the public
that in turn induce patients to demand services from their physicians;
the financial pressure on facilities; outright greed of a small minority
in the medical profession; the ongoing medical liability crisis and
the resultant practice of “defensive medicine”; a financing/reimbursement
system that gives incentives to provide services without regard to
outcomes. Regardless of the causes of the unnecessary provision, a
long-standing, compelling argument exists that a substantial number
of services provided by physicians and other practitioners in the
health care delivery system are simply unnecessary or only marginally
beneficial. Further, it is argued that it is these unnecessary services
that are driving up health care costs and spending in the aggregate.
And thus, proponents of this perspective argue that eliminating these
unnecessary and marginal services provides two essential goods: efficiency
and cost savings (Fisher et al 2003).
The work of Wennberg
and colleagues showing the diminishing rates of benefit to the community
of additional physicians can certainly be thought of as supporting
this perspective. Recently, the work of Fisher et al (2003a, 2003b)
showing the lack of relationship (and sometimes negative relationship)
between the provision of services, level of spending on services,
health care outcomes, and patient satisfaction provided another analysis
supporting the perspective.
Coming from a
slightly different perspective, Weiner (1994, 1995, 2004) and others
(Hart et al 1997; Goodman et al 1996) have attempted to estimate demand
for physician services in a way that bypasses these unnecessary services
by examining closed, organized systems of health care delivery that
employ more or less rigorous utilization review. In the early and
mid-1990s, these examinations revolved around staff-model HMOs. This
work has most recently evolved to examine large prepaid group practices
having contracts with managed care plans (Weiner 2004). The earlier
work found that staff-model HMOs were able to provide equivalent quality
of care with drastically smaller physician staffing levels. Those
who looked more closely at these organizations found that patients
were actually using many out-of-network services and challenged this
early work (Hart et al 1997). This work continues, however, and the
most recent updates show that although in the past these delivery
systems may have required lower staffing levels, over time they have
expanded. However, the expansion has not quite reached the levels
observed outside of these delivery systems (Weiner 2004).
For this alternative
scenario, the most important issue is estimating a level of unnecessary
services (or thought of differently, a percentage of services that
would not pass rigorous utilization review). The most recent work
(Fisher et al 2003b; Weiner 2004), suggests that approximately 26.5
percent of the services are unnecessary or would not occur under a
more rigorous system of utilization review. With that assumption made,
Table 15 presents the resultant projections of physician demand through
2020.12
Under this alternative
scenario, the growth in physician demand is approximately 150,000
FTE physicians (26 percent) between 2000 and 2020, in relative terms
equivalent to the baseline model. The results are the same for demand
expressed as a ratio of FTE physicians to 100,000 population. However,
in absolute terms, the results of this scenario are remarkable. Whereas
the baseline model predicts demand close to 1 million FTE physicians
in 2020, this alternative forecasts less than a 750,000 FTE demand
for physicians. This alternative scenario suggests that demand for
physicians in 2020 will be smaller than the baseline model predicts
for 2000.
Sensitivity
Analysis: Alternative Scenario Three
One estimate of
the effect of eliminating unnecessary services is presented above.
Below, a range is constructed around this estimate, and its implications
for physician demand are presented. In the low-effect scenario, only
20 percent could be identified and eliminated as unnecessary services;
whereas in the high-effect scenario, a full third of services could
be identified and eliminated as unnecessary. Table 16 presents the
results. Clearly, the relative change in demand for physicians is
unaffected by the assumption of the level of unnecessary services
that could be identified and eliminated. Rather, the absolute level
of demand is affected.
Alternative
Scenarios Four and Five: Hybrid Models—Economic Expansion and
Unnecessary Services/Increased Utilization Review; Changes in Age-Specific
Utilization Rates and Unnecessary Services/Increased Utilization Review
The next two alternative
scenarios involve an attempt to bring together the alternative demand
scenarios presented previously. In both Alternative Scenarios Four
and Five, the predicted expansion in demand due to either continued
economic expansion or increasing rates of utilization by the portion
of the population that is growing the fastest is coupled with efforts
to identify and eliminate unnecessary service provision. Alternative
Scenario Four couples economic expansion with utilization review,
whereas Alternative Scenario Five couples increasing utilization predictions
with utilization review. Tables 17 and 18, respectively, present the
results.
*UR = Utilization
Review
Applying the assumptions
of eliminating unnecessary services certainly appears to control the
great increases in demand for physicians predicted by either economic
expansion or the increasing rates of utilization of services among
specific groups within the population. The demand for close to 300,000
FTE physicians is eliminated under both of these alternative hybrid
scenarios.13
CONCLUSIONS:
DEMAND FOR PHYSICIANS IN THE U.S., 2000-2020
The baseline predictions
of growth in the demand for physicians suggest that demand will increase
by almost 210,000 FTE physicians by 2020, totaling over 987,000 physician
FTEs. When other factors are taken into consideration, such as economic
expansion and the observed increasing rates of utilization among those
age 45 and above, growth in demand, in fact, may increase an additional
300,000 FTE physicians during that same time period. Yet, this growth
is logical given the aging of the population; the Nation’s investments
in new and improved health and medical care services and procedures;
and the Nation’s continued increase in wealth. Given the findings
presented above, it is likely that the Nation will demand between
1,025,000 and 1,240,000 physicians in 2020.
Further, although
the Bureau of Labor Statistics (BLS) uses a different forecasting
methodology, it is worth noting that the BLS forecast for physician
job growth between 2000 and 2010 is 18 percent (Hecker 2001). In this
report, the estimate of growth in demand for physicians between 2000
and 2010 is between 17 percent and 19 percent. The similarities in
estimated demand provide some comfort with the current forecasts.
On the other hand, an important factor that is seldom taken into account
in predictions of demand for physician services is the level of unnecessary
services. Because demand is conceptualized as utilization of services
(rather than the desire for services), consideration of unnecessary
services is appropriate.14 The alternative scenarios presented
previously with regard to unnecessary services certainly imply that
it is an important factor in physician workforce planning. However,
the most difficult challenge to this perspective is developing solutions
that can effectively identify and eliminate the unnecessary services.
In the words of one major proponent of this perspective:
Previous
research has shown that vulnerable populations may be harmed by
reduced access to care or as a consequence of public hospital closures.
It is not always clear, for example, whether services such as specialist
consultations are wasteful or beneficial. The potential adverse
impact of reductions in the use of beneficial services and disruptions
in current practice patterns underscores the importance of further
research on these issues and of the implementation and evaluation
of demonstration projects intended to improve quality of care and
promote conservative approaches to managing patients with chronic
disease (Fisher et al 2003, p. 297).
The implication
of this position is to base policy decisions not on these initial
exploratory analyses of utilization and outcomes, but rather on more
targeted research results.
Future
Need for Physicians, 2000-2020
OVERVIEW
OF METHODOLOGY: BASELINE MODEL AND FACTORS AFFECTING FUTURE NEED
The need for physicians,
like demand, is defined with respect to current patterns of use of
physician services. However, the calculation of need also includes
the estimated levels of use of those who are currently uninsured if
they were to be insured. Thus, the need for physicians is defined
as the sum of current use plus anticipated use of the currently uninsured.
This conceptualization
of need assumes that on average persons with ready access to health
services will seek services commensurate with their need for those
services. It also assumes that persons currently uninsured would use
services at levels equal to those who are insured. In addition, based
on previous research on the non-financial barriers to health care
(e.g., racial disparities), it is assumed that the removal of such
access barriers will also lead to a modest increase in use for all
populations by 2.0 percent (Vector Research, Inc. 1995).
The baseline forecast
of need for physicians in the U.S. between 2000 and 2020, again, is
based on the Physician Demand Model (PDM). This model, developed and
maintained by the BHPr, HRSA, DHHS, produces projections of full-time
physician equivalents by specialty for 1995 through 2020. For the
purposes of this report, the years of interest are 2000 through 2020,
and the specialty groups of interest are generalists and non-generalists.
Estimates of need are generated by relaxing the assumption of historical
insurance rates and assuming that all uninsured in the Nation would
have (or would be provided) insurance. These assumptions are the basis
for the first baseline projections.15 Table 19 presents
baseline predictions of the need for physicians in the U.S. between
2000 and 2020.
It is important
to note that this conceptualization of need is unconventional. Typically,
need is defined according to either an ideal standard of health care
or staffing found existing in a limited population, geographic area,
or health care delivery system. In the final analysis, however, these
types of conceptualizations are subjective and open to unknown (and
sometimes unknowable) biases on any number of counts. The potential
biases and their direction can begin to be listed by using an empirical
conceptualization of need. First, the estimates of need based on this
conceptualization, in most cases, will be higher than the estimates
of demand (i.e., use). One possible scenario that would lead to higher
demand than need would be one in which the uninsured population actually
had higher rates of use as uninsured than they would with insurance.
Second, the estimates of need are likely to underestimate the actual
physician needs of the population. That is, there are other barriers
to use beyond insurance and the non-financial barriers for which the
baseline model cannot account. On the other hand, some would suggest
that an estimate of physician need should exclude unnecessary services.
Several alternative scenarios below present this perspective.
As described
above, in the baseline projections, the approximately 41 million persons
(Garrett, Nichols, and Greenman 2001) in the U.S. population who are
currently uninsured are assumed to have insurance and to use services
at the same rate as those who have historically had insurance. In
the baseline model, the need for physicians is projected to grow by
almost 300,000 FTEs (37 percent) between 2000 and 2020. Over the same
time period, the U.S. Census Bureau projects an 18 percent growth
in the U.S. population, yielding a net 16 percent growth in the per
capita need for physicians as expressed in an FTE physician-to-population
ratio. Unlike the supply of physicians, the need for physicians is
not projected to peak during the time period under investigation.
Moreover, relative to the baseline supply projections, the need for
physicians is projected to grow more quickly; thus, a shortage of
physicians is implied. The next section presents alternative forecasts
of the need for physicians and factors affecting the overall need
for physicians in the U.S.
ALTERNATIVE
NEED SCENARIOS AND ASSUMPTIONS
The first and
second alternative scenarios presented below combine the baseline
projections (full insurance assumptions) with scenarios identified
in the demand section of this report (specifically, the effect of
changing age-specific physician utilization rates and the effect of
the identification and elimination of unnecessary services, respectively).
A final scenario that combines the assumptions of a fully insured
population, the changes in age-specific utilization rates, and the
identification and elimination of unnecessary services is presented
and discussed. For each alternative scenario, a sensitivity analysis
is presented.
Alternative
Scenario One: Changes in Age-Specific Utilization Rates
In the first alternative
scenario predicting need for physicians in the U.S. between 2000 and
2020, the effects of continued changes in the age-specific physician
utilization rates discussed in the previous section on demand are
coupled with the effects of fully insuring the population of the U.S.16
It is noteworthy that the assumptions with respect to the changes
in utilization rates are the same as those assumptions for Alternative
Scenario Two in the demand section (i.e., the changes in age-specific
physician utilization rates observed between 1990 and 2000 would continue
between 2000 and 2010 and between 2010 and 2020). Table 20 presents
the ramifications of making these assumptions on the need for physicians
between 2000 and 2020.
Under Alternative Scenario One, the need for physicians is projected
to almost double to over 1,500,000 FTEs between 2000 and 2020. Over
the same time period, the U.S. Census Bureau projects an 18 percent
growth in the U.S. population, yielding a net 65 percent growth in
the per capita need for physicians as expressed in an FTE physician-to-population
ratio, moving from 283 physicians per 100,000 population to a staggering
468. The tremendous growth in the need for physicians in this scenario
is testament to the gravity of changing rates of utilization.
Sensitivity
Analysis: Alternative Scenario One
One major assumption
of the need projections is that once insured, the historically uninsured
will use physician services at the same rate as the historically insured.
For each alternative scenario presented in the need section, the sensitivity
analysis will relax that assumption by examining two levels of utilization
of services by the uninsured. On the low-use end, it is assumed that
once insured, the historically uninsured will use services at half
the rate of the historically insured. On the high-use end, it is assumed
that once insured, the historically uninsured will use services at
twice the rate of the insured. Both assumptions are legitimate, because
some have argued that the uninsured are likely to be younger and healthier
than the insured (which includes the older population on Medicare).
Thus, the uninsured are in less need of services than the historically
insured. At the same time, others have argued that the uninsured are
likely to be poor, un- or underemployed, and thus in need of greater
services than the historically insured. Table 21 presents the results
of this sensitivity analysis.
If the historically
uninsured use physician services at half the rate of the historically
insured population, between 2000 and 2020 there will be an increase
of close to 700,000 (89 percent) physician FTEs. On the other hand,
if the historically uninsured are on average more inclined to use
physician services, the model projects an increase in need of over
800,000 (104 percent) FTE physicians by 2020. This analysis demonstrates
that further research is needed to determine the exact effect of providing
insurance to the historically uninsured population in the U.S. Whether
the historical levels of utilization continue to hold in the future
will have, as shown above, an effect on the number of physicians needed
to adequately serve the population. Moreover, the analysis makes explicit
the fact that assumptions about potential future changes in age-specific
utilization rates have a much larger effect than assumptions about
the physician utilization of the historically uninsured.
Alternative
Scenario Two: Elimination of Unnecessary Services/Increased Utilization
Review
As mentioned previously,
in this second alternative scenario predicting need for physicians
in the U.S. between 2000 and 2020, the effects of being able to ferret
out unnecessary services through a rigorous utilization review process
identified in the previous section on demand are coupled with the
effects of fully insuring the population of the U.S. It is noteworthy
that the assumptions with respect to unnecessary services are the
same as those for Alternative Scenario Three in the demand section
(i.e., approximately 26.5 percent of the services provided currently
are unnecessary and these services could be identified and prevented).
Table 22 presents the results associated with this scenario.
Under this alternative scenario, the percentage growth (37 percent)
in need for physicians is exactly the same as the baseline need projections,
as was the case in the hybrid alternative models in the demand section.
Again, it is interesting to note that although the relative change
in need for physicians is the same, the level of service use is significantly
lower.
Sensitivity
Analysis: Alternative Scenario Two
The sensitivity
analysis presented below, in Table 23, shows the effect of altering
the assumption of use among the historically uninsured once they become
insured.
Alternative
Scenario Three: Changes in Age-Specific Utilization Rates; Unnecessary
Services/Increased Utilization Review Hybrid
In the final scenario,
assumptions are made beyond the baseline need model that incorporate
both changes in age-specific utilization rates and the identification
and elimination of unnecessary physician services through 2020. Combining
all factors is an attempt to predict the future need for physicians
in the U.S. the most accurately. The assumptions in this scenario
are exactly the same as the main assumptions on physician need in
Alternative Scenarios One and Two. Table 24 presents the results associated
with this scenario.
Under the final
alternative scenario, the need for physicians is projected to increase
substantially to more than 1,120,000 FTEs (95 percent) between 2000
and 2020. This scenario is slightly less than 50,000 FTE physicians
higher than the baseline need prediction. Over the same time period,
the U.S. Census Bureau projects an 18 percent growth in the U.S. population,
yielding a net 65 percent growth in the per capita need for physicians
as expressed in an FTE physician-to-population ratio, moving from
208 physicians per 100,000 population to 344. Although the need for
physicians does grow dramatically, efforts to identify and eliminate
unnecessary services assert control over the growth, limiting the
effects of changing patterns of physician utilization among a fully
insured population.
Sensitivity
Analysis: Alternative Scenario Three
Table 25 presents
the results of lower and higher rates of utilization among the historically
uninsured on the projections of the need for physicians between 2000
and 2020 for Alternative Scenario Three. As suspected, the increases
in physician need predicted by the model are slightly lower when the
utilization rates of the historically uninsured are assumed to be
half of what has been found in the past. The increases in physician
need are slightly higher when utilization rates of the historically
uninsured are assumed to be double what has been found in the past.
CONCLUSIONS:
NEED FOR PHYSICIANS IN THE U.S., 2000-2020
There is no single,
generally accepted standard for the number of physicians needed by
a community or Nation. One can hold up the current use of physicians
in communities with above-average health status indicators and set
their rates of utilization as a benchmark (Goodman et al 1996). However,
the differences between communities in terms of health delivery systems
and population needs are so significant that they raise serious questions
about the relevancy of using the workforce in one community for other
communities. Moreover, as has been pointed out in a number of studies
examining the correlation between community health status and the
size of health workforce in a community, once a certain size of the
health workforce is achieved, it is often difficult to measure the
associated increase or decrease in health status. Thus, for many communities
in the Nation, it might appear as though the size of the health workforce
(in this case, the physician workforce) is not correlated with the
health status of the community. The process of selecting the most
appropriate communities to use as benchmarks would entail a great
deal of additional analysis. Even then, this selection process would
be open to criticism as biased and not reflecting the population of
the Nation as a whole.
Therefore, for
purposes of this analysis, the national experience has been used to
compare the use of services by those with and those without heath
insurance. The linchpin assumption made was that if those without
health insurance were covered, they would use services at the same
rate as those with health insurance. The sensitivity analyses relaxed
the assumption, to some extent, which revealed the resultant effects
on the prediction of future physician need.
The model and
the alternative scenarios predicted a wide range of potential need
for physicians in the U.S. in the future. The baseline model predicted
an increase in need for physicians of 290,000 FTE physicians. The
variation in the predictions associated with the alternative scenarios
represented the results of assumptions having to do with other factors
related to the need for physicians, that is, the changes in age-specific
physician utilization rates and the identification and elimination
of unnecessary services. It seems reasonable that the scenario that
takes all factors into account (Alternative Scenario Three) is the
most accurate way to predict future need for physicians. When all
factors are taken together, then, the need for physicians is predicted
to grow between 300,000 and 390,000 FTE physicians between 2000 and
2020.
In sum, it is
predicted that there will be a need of between 1,086,000 and 1,173,000,
resulting in a shortage of physicians in 2020 in the range of 65,000
and 150,000. It is noteworthy that without successful efforts to identify
and eliminate unnecessary services, the physician supply-need gap
could be much greater.
Physician
Supply, Demand, and Need, 2000-2020: Specialty Mix Issues
One goal of the
current re-assessment of physician supply, demand, and need over the
coming decades is to determine the appropriate specialty mix. In COGME’s
Third Report (1992), a recommendation was made that one-half
of all new practicing physicians be of the generalist variety (pediatrician,
internist, family practitioner, and any combination). The recommendation
had effects on the cohort of medical students and residents training
in the 1990s thanks to a number of programs. The ranks of generalist
physicians grew more rapidly than those of non-generalist physicians
during the decade (Salsberg and Forte 2002). Toward the end of the
1990s, however, interest in generalist specialties began to wane,
as the non-generalist specialties, once again, became more attractive
to young physicians (Kimball 2000; AAMC 2002; Salsberg and Forte 2002).
In this section,
the issue of specialty mix is addressed with regard to physician supply,
demand, and need between 2000 and 2020. The strategy employed to address
this issue is one that looks at a variety of specialty mix levels
in an attempt to describe the physician supply, demand, and need if
those mixes were to occur. For each main outcome variable (supply,
demand, and need), the numbers of generalists and non-generalists
projected under these assumptions are presented: 1) of a continuation
of historical specialty mix patterns17; 2) of a move toward
more non-generalist-based medicine resulting in a 30 percent generalist
and 70 percent non-generalist physician supply; and 3) of a move toward
more generalist-based medicine resulting in a 45 percent generalist
and 55 percent non-generalist physician supply.18,19 The
baseline numbers of physicians are those projections identified in
the previous sections as the most likely to occur.
SUPPLY
OF GENERALIST AND NON-GENERALIST PHYSICIANS: BASELINE PROJECTIONS
In Section II,
“Supply of Physicians,” a combination of the baseline model
and Alternative Scenario Three was identified as the most likely scenario
for physician supply. In this scenario, both lifestyle changes among
the physician workforce and productivity enhancements due to technological
developments were considered. In terms of specialty mix, historical
patterns suggest a slight move toward more generalist physicians (slightly
less than 37 percent in 2000 to slightly more than 39 percent in 2020).
Given these assumptions, Table 26 presents the supply of generalists
and non-generalists in the U.S. from 2000 to 2020.
A small change
in the specialty mix has a large impact on the relative growth rates
of generalists and non-generalists between 2000 and 2020. If the historical
patterns continue, generalists will grow by 116,000 FTE physicians
(40 percent), adding 20 FTE physicians per 100,000 population. Non-generalists
will grow by some 127,000 FTEs (26 percent), adding about 12 FTE physicians
per 100,000 population.
Supply Specialty
Mix Alternative Scenario One: Non-Generalist Dominant Mix
As mentioned at
the beginning of this section, generalist specialties have begun to
lose favor among young physicians and those still in training, so
it is unclear whether the patterns observed in the mid-1990s will
continue in the future. The ramifications of a move toward a more
non-generalist mix (in terms of the supply of physicians) are explored
in this alternative scenario. In this scenario, instead of an increase
in the generalist specialties, the mix is weighted toward a non-generalist
mix. Specifically, it is assumed that by 2020, generalists will make
up just 30 percent of the physician supply, whereas non-generalists
will make up 70 percent. Table 27 presents the results of this change.
The move toward
a specialty mix that is more non-generalist, dominated over the next
two decades, seriously depletes the future generalist supply. Growing
by less than 20,000 FTEs (7 percent) between 2000 and 2020, generalist
physician growth does not keep up with population growth. On the other
hand, the non-generalist supply grows by nearly 50 percent (223,000
FTE physicians), continuing to outpace population growth.
Supply
Specialty Mix Alternative Scenario Two: Generalist-Weighted Mix
Certainly, some
observers argue that the Nation would be better served having more
generalist physicians. This scenario presents what the physician supply
would look like if by 2020, the overall specialty mix of physicians
approximated a 45 percent generalist and 55 percent non-generalist
mix. Table 28 presents the results.
With a move toward
a more generalist-weighted specialty mix over the time period of investigation,
a very different physician supply results. Generalists grow by 174,000
FTE physicians (61 percent), adding about 37 FTEs per 100,000 population.
The non-generalists grow by about 70,000 FTE physicians (14 percent),
paralleling the growth of the population through 2010. Growth among
the non-generalist physician supply begins to fall behind the overall
population growth, however, after 2010.
DEMAND
FOR GENERALIST AND NON-GENERALIST PHYSICIANS: BASELINE PROJECTIONS
In Section III,
“Future Demand for Physicians,” Alternative Scenario Two
was identified as the most likely scenario for future demand for physicians
in the U.S. In this scenario, the age-specific utilization rate changes
observed between 1990 and 2000 were projected to continue from 2000
to 2010 and from 2010 to 2020. In terms of specialty mix, historical
demand patterns suggest a slight move toward more generalist physicians
(slightly less than 37 percent in 2000 to slightly more than 37 percent
in 2020). Starting from this baseline, and applying historical patterns
of the demand for generalists and non-generalists, Table 29 presents
the demand for generalists and non-generalists in the U.S. from 2000
to 2020.
Because of the
slight change in the specialty demand mix, the demand for generalists
and the demand for non-generalists grow at similar rates in this scenario
(44 percent and 41 percent, respectively). In terms of relative demand
for physicians, demand grows from 104 generalist FTEs per 100,000
population in 2000 to 126 in 2020. At the same time, demand for non-generalists
grows from 179 non-generalist FTEs per 100,000 to 214. Compared to
the baseline specialty projections of supply, the Nation will experience
a shortage of generalists (9,000 FTEs), as well as non-generalists
(75,000 FTEs). If the specialty mix in the supply is as projected
in Alternative Scenario One above, the shortage of generalists will
be exacerbated, whereas the shortage of non-generalists will be eliminated,
with a small surplus (30,000 FTEs) throughout most of the period.
In a more generalist-weighted supply scenario (Alternative Supply
Specialty Mix Scenario Two above), there is a surplus of generalists
(49,000 FTEs) and a shortage of non-generalists by 2010 that grows
larger through 2020.
Demand Specialty
Mix Alternative Scenario One: Non-Generalist Dominant Demand Mix
In this scenario,
the demand for physicians in 2020 is such that 30 percent of the physicians
demanded are generalists and 70 percent are non-generalists. Generalists
account for approximately 9 percent less of the total demand for physicians
in this scenario compared to the baseline demand specialty mix. Non-generalists
account for approximately 9 percent more of the total demand for physicians
than in the baseline assumptions. Table 30 presents the demand for
physicians under these assumptions.
In this scenario,
demand for generalists and non-generalists grows in absolute terms
through the period of interest. Demand for generalists grows at approximately
the same rate as the population, remaining at 102 FTE physicians per
100,000 from 2005 on, while demand for non-generalists increases 57
percent in terms of FTEs and 33 percent in terms of FTEs per 100,000
population. Compared to the baseline specialty projections of supply,
the Nation will experience a significant surplus of generalists (70,000
FTEs), as well as a large shortage of non-generalists (155,000 FTEs).
If the specialty mix in the supply is as projected in Alternative
Supply Specialty Mix Scenario One above, the surplus of generalists
would be lessened to approximately 25,000 FTEs, and the shortage of
non-generalists would be lessened substantially as well. In a more
generalist-weighted supply scenario (Alternative Supply Specialty
Mix Scenario Two above), there is a large surplus of generalists (128,000
FTEs). There is also a shortage of non-generalists by 2005 that grows
larger through 2020.
Demand Specialty
Mix Alternative Scenario Two: Generalist-Weighted Mix
In this scenario,
the demand for physicians in 2020 is such that 45 percent of the physicians
demanded are generalists and 55 percent are non-generalists. Compared
to the baseline demand specialty mix, in this scenario generalists
account for approximately 6 percent more of the total demand for physicians
than in the baseline scenario. Non-generalists account for approximately
6 percent less of the total demand for physicians than in the baseline.
Table 31 presents the demand for physicians under these assumptions.
In this scenario,
demand for generalists and non-generalists grows in absolute terms
through the period of interest. Demand for generalists grows at a
substantial rate, moving from 104 FTE physicians per 100,000 in 2000
to 153 in 2020. Demand for non-generalists increases 23 percent in
terms of FTEs and 5 percent in terms of FTEs per 100,000 population,
a far slower pace than that of generalists. Compared to the baseline
specialty projections of supply, the Nation will experience a significant
shortage of generalists (97,000 FTEs), as well as a small surplus
of non-generalists (12,000 FTEs). If the specialty mix in the supply
is as projected in Alternative Supply Specialty Mix Scenario One above,
the shortage of generalists will be exacerbated to approximately 192,000
FTEs and the surplus of non-generalists will be greatly increased
as well. In a more generalist-weighted supply scenario (Alternative
Supply Specialty Mix Scenario Two above), there would be a shortage
of generalists (40,000 FTEs) and a shortage of non-generalists (46,000
FTEs) in 2020.
NEED
FOR GENERALIST AND NON-GENERALIST PHYSICIANS
In Section IV,
“Future Need for Physicians,” Alternative Scenario Three
was identified as the most likely scenario for future need for physicians
in the U.S. In this scenario, the age-specific utilization rate changes
observed between 1990 and 2000 were projected to continue from 2000
to 2010 and from 2010 to 2020. Further, this scenario also accounted
for unnecessary services that would be weeded out by a strong utilization
review process. In terms of specialty mix, historical need patterns
suggest a slight move toward more generalist physicians (slightly
less than 37 percent in 2000 to slightly more than 37 percent in 2020).
Starting from this baseline, and applying historical patterns of the
need for generalists and non-generalists, Table 32 presents the projected
need for generalists and non-generalists in the U.S. from 2000 to
2020.
Because of almost
negligible changes in the specialty need mix, the demand for generalists
and the demand for non-generalists grow at similar rates in this scenario
(97 percent and 94 percent, respectively). In terms of relative need
for generalist physicians, need grows from 76 generalist FTEs per
100,000 population in 2000 to 127 generalist FTEs in 2020. At the
same time, need for non-generalists grows from 132 to 216 non-generalist
FTEs per 100,000. Compared to the baseline specialty projections of
supply, the expected physician workforce will experience a shortage
of generalists (13,000 FTEs), as well as non-generalists (83,000 FTEs).
If the specialty mix in the supply is as projected in Alternative
Supply Specialty Mix Scenario One above, the shortage of generalists
will be greatly increased, reaching over 100,000 FTEs by 2020. The
shortage of non-generalists will be reversed, with a large initial
surplus shrinking throughout the period. In a more generalist-weighted
supply scenario (Alternative Supply Specialty Mix Scenario Two above),
there is a surplus of generalists (35,000 FTEs). There is also a shortage
of non-generalists by 2010 that grows larger through 2020.
Need Specialty
Mix Alternative Scenario One: Non-Generalist Dominant Need Mix
In this scenario,
the need for physicians in 2020 is such that 30 percent of the physician
need is associated with generalist services and 70 percent with non-generalist
services. Compared to the baseline demand specialty mix, in this scenario
generalists account for approximately 9 percent less of the total
need for physicians than in the baseline scenario. Non-generalists
account for approximately 9 percent more of the total need for physicians
than in the baseline assumptions. Table 33 presents the need for physicians
under these assumptions.
