1. The Expected Physician Shortage: Implications for the Physician Assistant Workforce Edward Salsberg Associate Vice President Director, Center for Workforce Studies Association of American Medical Colleges Presentation to: Physician Assistant Education Association Quebec City October 26, 2006

2. Overview of Presentation 1. New AAMC Physician Workforce Position Statement 2. The Evidence of a Likely Physician Shortage 3. Factors Likely to Influence Demand and Supply 4. Challenges for the Medical Education Community 5. Implications for the Physician Assistant Workforce

3. AAMC’s 2006 Workforce Position Expand US MD enrollment by 30% by 2015 Eliminate GME caps Leave specialty choice up to students Expand NHSC by 1500 positions Increase the diversity of the workforce Conduct a study of geographic distribution Examine options for assessing medical schools outside of the US targeted to Americans Encourage improved medical education in less developed parts of the world

4. Cycles and Shifts in US Physician Workforce Concerns and Policies 1950 – late 1970s: Concern with physician shortages; federal funding to expand medical school capacity and enrollment 1980 – 2000: Concern with potential surpluses; federal recommendations to limit growth of physician supply 2000 - 2005: Growing concern with potential shortages 2006: General consensus on likely shortages

5. Physician Workforce Planning in the US Extensive state support for undergraduate medical education Medicare and Medicaid GME funding No national planning system Resistance to central control  Limited federal guidelines  Limited use of fiscal incentives  Limited data for planning Market dominated: 25,0500 new physicians each year distributed across more than 150 specialties/sub-specialties and 50 states

6. Challenges to Effective Physician Workforce Planning  Very long time frames to change supply or distribution  Uncertain impact of medical advances  Uncertain future organization, finance, delivery  Lack of good or consistent data  Difference between demand vs. need  Lack of responsibility for physician workforce planning

7. The Evidence of a Likely Physician Shortage is Growing

8. Recent Specialty Specific Reports of Shortages Allergy and Immunology Cardiology Critical Care Dermatology Emergency Medicine Endocrinology Family Practice Geriatric Medicine Internal medicine Psychiatry/Child and Adolescent Psychiatry Pediatric Subspecialties Radiology Prepared by AAMC Center for Workforce Studies

9. Recent State Reports Related to Shortages Arizona California Georgia Kentucky Massachusetts Michigan Mississippi Nevada North Carolina Oregon Texas Wisconsin Prepared by AAMC Center for Workforce Studies

10. Unmet Need Already Exists--30 million People Live in Federally Designated Shortage Areas Source: HRSA/AAFP

11. Key Factors Influencing Future Demand for Physician Services Population growth↑ Aging of the population ↑ Public expectations ↑ Economic growth of the nation ↑ National investment in health care interventions ↑ Improved diagnosis and treatment ↑↓ Changes in organization, delivery, financing ↑ ↓ Cost containment efforts ↓

12. Number of Americans Over 65 will Grow by 35 Million Between 2000 - 2030 Source: U.S. Census; Prepared by AAMC Center for Workforce Studies 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 2000201020202030 65+: 104% increase from 2000 to 2030 85+: 127% increase from 2000 to 2030

13. The Eleven Most Costly Medical Conditions Are Far More Prevalent Among the Elderly, US 2000 ConditionTreated Prevalence per 100,000 Spending (millions of dollars) % in total health care spending Heart disease 6,22656,700 9% Trauma 12,33841,100 7% Cancer 3,34838,900 6% Pulmonary conditions 15,52636,500 6% Mental disorders 8,57534,400 5% Hypertension 11,38223,400 4% Diabetes 4,26018,300 3% Arthritis 6,96617,700 3% Back problems 5,09217,500 3% Cerebrovascular disease 85415,000 2% Pneumonia 1,37012,600 2% Total 312,000 50% Source: Thorpe, K.E., C.S. Florence, & P. Joski (2004) Prepared by AAMC Center for Workforce Studies

14. Age-Specific Cancer Incidence Rates/100,000, 2000 Source: CDC, Age-Specific Invasive Cancer Incidence Rates by Primary Site and Race, United Sates (U.S. Cancer Statistics, 2000). Prepared by AAMC Center for Workforce Studies Age Group

15. Utilization of Physician Services Rise with Age and Over Time Ambulatory Care Visits to Physician Offices and Clinics Source: NAMCS 1980, 1990, 2000 & 2004 Prepared by AAMC Center for Workforce Studies

16. Factors Influencing Future Supply Medical school production (MD, DO) International migration and IMG policies Aging of physician workforce & retirement Gender and generational differences Lifestyle choices Changing practice patterns Productivity changes (i.e. NPs/PAs, IT) Total Numbers Impacts “effective” supply

17. The Physician Workforce is Aging: 250,000 Active Physicians are Over 55 Source: AMA PCD for 1985 data; AMA Masterfile for 2005 data. Active physicians include residents/fellows NOTE: 1985 data excludes 24,000 DOs. Prepared by AAMC Center for Workforce Studies, Mar 2006

18. Prepared by AAMC Center for Workforce Studies, May 2006 0 5,000 10,000 15,000 20,000 25,000 30,000 200020052010201520202025 New Physicians Retirements/Departures Physician Retirements Will Grow Rapidly Over the Next 20 Years

19. The Percent of Physicians That are Female Is Rising Steadily Source: AAMC Facts; AMA PCD 2006 Edition. Prepared by AAMC Center for Workforce Studies, Jan 2006 MD Graduates: Percent Female Patient Care MDs: Percent Female

20. International Medical School Graduates (IMGs): Why the Concern Now?  International concern about brain drain from less- developed to more-developed countries. Global shortage of human resources in health.  Reliance on other countries for a vital resource in a period of international uncertainty: more than 6,400 IMGs enter GME each year equal to 1 of 4 new physicians.  Growth of off-shore for-profit schools primarily for US citizens but outside of US accrediting systems (15 new schools in the past decade) and a concern with the quality of education of the 1,500 US-IMGs entering GME annually.  As many as 2,500 US-citizens each year now enter a foreign medical school.

21. First-Year Enrollment at Osteopathic Schools May be as High as 5,700 by 2015 Note: Percent Increase from 2002-03 Source: Osteopathic Workforce Summit, January 2006 Prepared by AAMC Center for Workforce Studies, February 2006, preliminary projections

22. Per Capita MD Enrollment Has Fallen Since 1980; Even With a 30% Increase, The Rate will Still be Below 1980 First Year Enrollment per 100,000 Source: AAMC Data Book; US Census Bureau. Prepared by Center for Workforce Studies, AAMC, Feb 2006.

23. US MDs Are Less Than 2/3 of Physicians Entering Graduate Medical Education, 2005 24,735* entered in ACGME and AOA training in 2005: * Includes both allopathic and osteopathic residents. + Number of DO graduates projected by AACOM. All the graduates are assumed to have entered ACGME or AOA GME. Sources: AMA and AACOM, 2004 Annual Report on Osteopathic Medical Education Prepared by the AAMC Center for Workforce Studies (Osteopathic Graduates in ACGME Training 1,478) 15,329 (62%) 2,888 + (12%) 65 (0.3%) 6,436 (26%) 17 (0.1%) (US IMGs 1,462)

24. Future Supply and Demand: The Bottom Line  Under current levels of MD production, the physician to population ratio in the US will peak between 2016 and 2021.  The baby boom generation – with record numbers of individuals and high expectations - will begin to turn 70 years old in 2016.

25. Active Physicians per 100,000 Pop 2005 –2030 With and Without an Increase in MD Enrollment Includes residents and fellows. Prepared by Center for Workforce Studies, AAMC, Mar 2006.

26. Challenges to US Medical School Expansion

27. Allopathic Schools P lans to Increase First-Year Enrollment Between 2005 and 2011 Results of 2005 Survey of Deans (116 of 125 schools)

28. Projected First-Year Enrollment at Allopathic Schools Through 2016 Preliminary Estimates High (18,453, 12% increase) Low (17,912, 9% increase) 16,448 (2002-03)) Sources: AAMC Data Book (2006) and 2005 AAMC Medical School Enrollment Survey Prepared by AAMC Center for Workforce Studies, February 2006

29. Potential Barriers to Enrollment Expansion: Percent of Medical Schools Indicating a "Major" or "Very Significant" Problem, 2005 Survey Source: 2005 AAMC Medical School Enrollment Survey Prepared by AAMC Center for Workforce Studies, February 2006

30. Growth of Physicians in ACGME Training Programs, 1995-2006 Total ACGME Residents*IMGs Entering GME + DO Grads/(Entering ACGME) 1995-9698,0355,4101,843 1996-9798,0765,3791,932 1997-9898,1435,4142,009 1998-9997,3835,3712,096 1999-0097,9895,9052,169 2000-0196,8066,0972 279 (1,242) 2001-0296,4106,1702 510 (1,304) 2002-0398,2586,2082,635 (1,287) 2003-0499,9646,0042,607 (1,473) 2004-05101,2916,1222,756 (1,535) 2005-06 103,106 6,436 2,888 (1,478) Change (‘96 – 2006) +5,071(+5.2%) +1026 (+19%) +1048 (+56.7%) (+236/19%) * Physicians in ACGME-accredited and in combined specialty GME programs. The numbers are as of August 1 of calendar year. + Based on From 246 filings as of August 2004. The 2004 number is from the 2005 JAMA Medical Education Sources: JAMA Medical Education Issues, 1991-2006 (Appendix II, Tables 1 and 4), ECGME, AOA and AACOM Annual Reports (2003 and 04) Prepared by the AAMC Center for Workforce Studies, September 2006

31. The 2020 Physician Supply Problem Must Be Addressed Now  3 to 5 years to add med education capacity  4 years of medical school  3 to 7 years of training Total: 10 to 16 years before a small marginal increase in numbers  An increase of 30% in US MD graduates phased in over the next decade will only add about 33,000 physicians by 2020

32. The US Has a Relatively Low Supply of Physicians Compared to other Developed Countries Physicians Per 100,000 (2000) Source: The Supply of Physician Services in OECD Countries. OECD, Steven Simoens & Jeremy Hurst. Health Working Papers. 2006

33. What Factors Will Influence Retirement? Source: 2006 AAMC Survey of Physicians Over 50 % “ Important” Very Somewhat Increased regulation of medicine43% 31% Stress of practice42% 37% Insufficient reimbursement42% 28% Decreasing clinical autonomy38% 31% Rising malpractice costs37% 26% On call responsibility36% 27% Lack of professional satisfaction31% Interest in pursuits not related to medicine26% 40% Personal health issues22% 26% Effort to keep clinically current19% 35% Increased family responsibilities14% 26% Recertification requirements13% 26% Increasing competition in specialty 8% 22% Occupational safety issues 6% 18%

34. Strategies to Balance the Supply and Demand for Physicians and to Meet Future Service Needs 1.Increase US medical school enrollment and graduations and GME positions 2.Retain active physicians longer 3.Increase productivity & effectiveness 4.Create a new more efficient health system that requires fewer physicians

35. Key Questions for Academic Medicine 1. How much of the future demand/need will be met by physicians vs. others? 2. How much of the MD increase should be through expansion of existing vs. new schools? 3. Whatever the increase in MD grads, how can they be educated and trained in an efficient and effective manner? 4. How can we better assure diversity of the workforce? 5. How do we prepare physicians to work in teams?

36. The Growing PA Workforce

37. Clinically Active PAs Have Nearly Tripled in the Past 15 Years (in thousands) Source: American Academy of Physician Assistants

38. The Number of PAs Will Continue to Grow Rapidly as the Number of New Graduates Per Year Has Tripled in the Past 15 Years Source: American Academy of Physician Assistants

39. Percent New PAs Going into Generalist Specialties Decreased Over Past 15 yrs While Sub-specialists Have Increased Sources: AAPA Membership Census Survey, 1991-1995; AAPA Physician Assistant Census Survey, 1996-2005. *PAs graduating in year immediately preceding the census reference year are considered New Graduates. Generalists Decreasing Specialists Increasing

40. Percent of New PAs Going into Primary Care (IM,Peds,FP) is Decreasing Source: American Academy of Physician Assistants

41. Percent of New PAs* Entering Family Medicine Each Year, 1991-2005 Sources: AAPA Membership Census Survey, 1991-1995; AAPA Physician Assistant Census Survey, 1996-2005. *PAs graduating in year immediately preceding the census reference year are considered New Graduates. Family Medicine

42. The Number of US MDs Entering Family Practice Through the NRMP Parallels the Rise and Fall of PAs Going into Family Practice Source: NRMP

43. Physicians That Regularly Work with NPs/PAs Agree that it Improves Efficiency and Care Source: 2006 AAMC Survey of Physicians Under 50 – Preliminary Results

44. The Future Team care Collaboration on education and training Collaboration on policy and program development Collaboration on data collection and analysis and workforce research