1. The U.S. Physician Workforce: Beyond the Numbers The U.S. Physician Workforce: Beyond the Numbers Richard A. Cooper, M.D. Leonard Davis Institute of Health Economics University of Pennsylvania National Health Forum Washington, DC February 13, 2006

2. 1. High quality health care requires adequate numbers of high quality physicians. 2. The demand for health care services nationally will continue to mirror the pace of economic growth. 3. Variation in the health care utilization among states will continue to reflect regional differences in economic status. 4. Variation of health care utilization among small areas (hospital regions, counties) will continue to reflect the additional burden of socioeconomic disparities. 5. The training capacity of medical schools and residency programs must be enlarged commensurate with the future demand that flows from these economic and demographic realities. PHYSICIAN WORKFORCE - BEYOND THE NUMBERS

3. GROWTH of ECONOMIC CAPACITY GROWTH of HEALTH CARE SPENDING DEMAND for PHYSICIANS Aging Burden of Disease Technology

4. 1929  2000  Economic and demographic trends predict a continued growth in the demand for physicians Approx 2020-2025  GDP  2.0% per capita per year GDP  1.0%  Health spending  ~1.5%  Health workforce  ~1.2%  Physician workforce  ~ 0.75%

5. 1929  2000  Projected Supply But supply will not keep up with demand. Approx 2020-2025 

6. And the “Effective Supply” will even be less. And the “Effective Supply” will even be less. 1929  2000  Projected Supply Effective Supply AgeGenderLifestyle Duty hours Career paths Approx 2020-2025 

7. Physicians per 100,000 of Population Variation in physician supply among states will continue to reflect differences in economic status.

8. State Physician Supply and Per Capita Income 1970 DC Excluded Data from Reinhardt, 1975

9. State Physician Supply and Per Capita Income 1996 DC Excluded

10. State Physician Supply and Per Capita Income 2004 DC Excluded

11. Constant Relationship between State Physician Supply and Per Capita Income Spanning 35 years. 1970,1996 and 2004 1970 data from Reinhardt, 1975 DC Excluded

12. DARTMOUTH  More is Worse  STATES “States with more medical specialists have higher costs and lower quality of care.” Baicker and Chandra, 2004

13. State Quality vs “Physicians” Baicker and Chandra (Dartmouth “Residuals”) State Quality Rank Higher  QUALITY  Lower MoreSpecialists---------------- LowerQuality Physician variable = “residuals after controlling for total physician workforce.”

14. State Quality Rank Higher  QUALITY  Lower State Quality vs Physicians Cooper (Actual Data) State Quality vs Physicians Cooper (Actual Data) MoreSpecialists---------------- HigherQuality Physician variable = Physicians

15. DARTMOUTH  More is Worse  SMALL AREAS Among Hospital Referral Regions (HRRs) with similar health status, those with the greater expenditures do not have ▪ Better outcomes ▪ Better outcomes ▪ Better access to care ▪ Greater satisfaction Fisher, et al, 2003

16. 306 HOSPITAL REFERRAL REGIONS (HRRs) Milwaukee HRR

17. Demographics of HRRs % Metro Fisher, Ann Int Med, 2003 87% Metro 45% Metro Low Cost High Cost

18. Demographics of HRRs % Black + Latino Fisher, Ann Int Med, 2003 17% Black + Latino 6% Black + Latino Low Cost High Cost

19. WISCONSIN HOSPITAL REFERRAL REGIONS (HRRs) Milwaukee HRR

20. Wisconsin HRRs Hospital days per 1,000 Ages 18-64 Milwaukee HRR

21. “Poverty Corridor” 42% of total population 92% of Black population 74% of Latino population 33% of income MILWAUKEE HOSPITAL REFERRAL REGION

22. Wisconsin HRRs Hospital days per 1,000 Ages 18-64 Milwaukee HRR  minus “Corridor” Poverty Corridor Milwaukee HRR

23. “The quantity of healthcare resources determines the frequency of use.” “Variations are unwarranted because they cannot be explained by the type or severity of illness.” Wennberg, BMJ 2002 DARTMOUTH  More is Worse  FREQUENCY OF USE “Supply-sensitive Services”

24. FREQUENCY OF USE Hospital Admissions in Poorest vs. Wealthiest Zones of Milwaukee

25. “Our analyses (of end-of-life care) found three-fold differences in physician FTE inputs for Medicare cohorts cared for at Academic Medical Centers. Given the apparent inefficiency of current physician practices, the supply pipeline is sufficient to meet future needs through 2020.” DARTMOUTH  More is Worse  FREQUENCY OF USE Academic Medical Centers Goodman et al, 2005

26. “Physician Inputs” into End-of-Life Care at Academic Medical Centers Goodman, et al, 2005 15 AMCs 15 AMCsNewarkChicago Houston (2) Philadelphia (3) New York (2) Los Angeles Detroit (2) WashingtonBostonPittsburgh NYU 63 AMCs

27. “Physician Inputs” into End-of-Life Care at Academic Medical Centers Goodman, et al, 2005 NYU 63 AMCs Three-fold 15 AMCs 15 AMCs In large In large urban urban centers centers

28. More care should yield better outcomes, but… …patients who receive the most needed care have ▪ more measured burden of illness ▪ more unmeasured burden of illness ▪ worse outcomes. “Counter-clinical Conclusion” Kahn, et al. HSR Feb 2007 At the extreme: Intensive care units (ICUs) offer the most needed care but have the worst mortality.

29. WHAT’S POSSILE FOR THE FUTURE?

30. Demand Supply The Supply-Demand dilemma 200,000 too few physicians Residencies capped at 1996 level Residencies capped at 1996 level

31. Increasing PGY-1 residency positions by 10,000 (40%) over the next decade is essential, but even that will not close the gap… Demand Supply +1,000/yr 2010-2025 No change No change AAMC projects 17% increase in medical school enrollment by 2012 = 2,500 additional physicians/year in 2020

32. …and the gap will continue for decades. None of us has ever experienced shortages such as these. Demand Supply +1,000/yr 2010-2030 No change

33. 1. The training capacity of medical schools and residency programs must be enlarged commensurate with future economic and demographic demands. 2. Because so much time has been lost, chronic shortages of physicians seem inevitable. 3. Inadequate domestic production will cause a further drain of physicians from other countries, principally developing countries. 4. An inadequate supply of physicians will lead to decreased access to care for the most needy and deficiencies in care overall. PHYSICIAN WORKFORCE -- BEYOND THE NUMBERS

34. Thank you

36. ZIP Code Comparison “Individual” Inverse relationship Comparison of Nations “Society” Direct relationship Economic Correlates and Units of Analysis US Small Area Analyses of Counties (3,141) and HRRs (306) are intermediate between ZIP Codes (~25,000) and States or Nations

37. Economic growth will continue, and health care spending will continue to grow more rapidly than the economy overall. CMS Cutler NOTE: Under President Bush’s proposed 2007 budget, annual growth of Medicare spending would “shrink” from 8.1%, as currently projected, to 7.7%.. NOTE: Under President Bush’s proposed 2007 budget, annual growth of Medicare spending would “shrink” from 8.1%, as currently projected, to 7.7%..

38. Demand If PGY-1 positions had continued to increase after 1996 at 500 per year Supply Had residency programs continued to expand after 1996, the US would not now be facing severe shortages.

39. Demand Implementation of the 110% Rule in 1996 Supply But had the “110% Rule” been put into place in 1996, the current deficits would be even greater.