What Physician Shortage? An Evidenced-Based Perspective David C. Goodman, MD MS Professor of Pediatrics and of Health Poli...
Workforce Research at The Center for Health Policy Resarch  <ul><li>John Wennberg, MD MPH  </li></ul><ul><li>Elliott Fishe...
The Workforce Crisis <ul><li>Why do many believe that there is a workforce crisis? </li></ul><ul><li>Would patients benefi...
U.S. Workforce Policy: From Surplus to Shortage <ul><li>1997: Surplus of physicians. </li></ul><ul><li>2005: Council on Gr...
Physician Training - 2000 US Medical Grads ~16,000 per yr Graduate Med Education entry = ~22,000 per yr  Clinical  Practic...
What is the evidence for an impending shortage? <ul><li>Growing population, particularly of the elderly. </li></ul><ul><li...
AAMC Projected National Supply &  Shortfall of Physicians with GME Expansion Source: Salsberg.  International Medical Work...
AAMC Projected National Supply & Shortfall  of Physicians with GME Expansion Source: Salsberg.  International Medical Work...
The 2020 “Shortfall” in Physicians Council on Graduate Medical Education. Sixteenth Report. 2005. 1,076,000 972,000 1,240,...
An alternative approach: What are the desirable outcomes of investing  in the medical workforce? <ul><li>Access:   to care...
If we agree on the desirable outcomes... Then the question is:  What are the most effective and efficient ways to achieve ...
<ul><li>Is there  evidence  that access, quality, and outcomes are sensitive to physician supply, per se? </li></ul>
www.dartmouthatlas.org John Wennberg  Lead Author Co-authors: Elliott Fisher, MD MPH David Goodman, MD MS Jonathan Skinner...
The Per Capita Supply of Physicians  Varies ~200% Across Regions Post-GME clinicians per 100K population age sex adjusted ...
Clinically Active Physicians per 100,000 Residents by Hospital Referral Region (2005), age-sex adjusted 215 to  316 (57) 2...
Regional variation in physician supply is not explained by: <ul><li>Patient health status or health risk Chan R, et al.  P...
 Neonatologists * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *...
Source: Wennberg, et al.  Dartmouth Cardiovascular Atlas There is virtually no relationship between regional physician sup...
Regional variation in physician supply is not explained by: <ul><li>Patient health status or health risk </li></ul><ul><li...
So what? Despite the idiosyncratic location of physicians... maybe more physicians leads to better health outcome.
Do areas with higher physician supply have  better health outcomes? Source: Goodman, Fisher, et al. New Engl J Med, 2002. ...
With Similar Outcomes, Many Health Care Systems Deliver Care with Far Fewer Physicians Standardized Physician Labor Input ...
FTE Primary Care Physician Labor Inputs per 1,000 Decedents During the Last Two Years of Life Cedars-Sinai Med Ctr 14.6 NY...
FTE Medical Specialist Labor Inputs per 1,000 Decedents During the Last Two Years of Life Cedars-Sinai Med Ctr 31.6 NYU Me...
Are Technical Quality and Patient Satisfaction Better with More Physicians? Goodman DC, Fisher ES. New England J Med, 2008...
Are Technical Quality and Patient Satisfaction Better with More Physicians? Goodman DC, Fisher ES. New England J Med, 2008...
Why is there such a weak association between workforce supply and outcomes?
Examples of Medical Decision Uncertainty that  Lead to Different Labor Demand <ul><li>84 y.o with mild CHF, diabetes, and ...
Inpatient back surgery per 1,000 Medicare enrollees (2005) 1.0 3.0 5.0 7.0 9.0 11.0 Back surgery per 1,000 enrollees Minne...
So what? Yes, physician are located idiosyncratically. And maybe outcomes aren’t sensitive to physician supply. Still, wou...
High Physician Supply/Cost Regions: <ul><li>Less likely to provide primary care. </li></ul><ul><li>Lower perceived access ...
Where do more physicians go? Number of Atlas Regions by Physicians per 100,000 population Source: Goodman. Health Affairs,...
What about the costs of expanding medical schools and removing the Medicare GME funding cap?  No published estimates... pr...
Medicare Costs and Non-Interest Income by Source as a Percent of GDP % GDP 2019 Part A trust fund goes broke Part B and D ...
Where would you invest $5-10 billion per annum of public money in the health care system? <ul><li>Implementation of the U....
Since when did we start trusting market forces to deliver good health care?
Does “Demand” Equal Consumer “Wants?” <ul><li>Consumers can judge quality. (e.g. Consumers Report) </li></ul><ul><li>Lot’s...
Market forces are like gravity... Each help you get where you want to go,  but you wouldn’t want to throw away  the steeri...
Restoring Accountability to  Health Workforce Planning <ul><li>Decisions about numbers and specialty mix of physician trai...
Beyond the workforce “crisis” <ul><li>Physician supply varies 2 - 3 fold, generally without differences in outcomes (healt...
 
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  • .
  • $297 million Children’s Hospital GME 2006
  • The work I will present comes from the Dartmouth Atlas of Health Care working group which includes my colleagues Wennberg, Fisher, and Skinner
  • The primary motivation for examining regional variation in the workforce has not been to ascertain underserved populations. There are other methods that can be used for that. It is to question the assumption that more physicians are necessarily better, or that fewer are necessarily worse for patients and populations. This is a familiar figure - the 306 HRR used in the Dartmouth Atlas are represented according to the post-GME clinicians per 100K. The range of physician supply is tremendous. What can we learn from this variation.
  • We can also look at more specific indicators of population disease burdens. CAD disease and its major acute events, AMI vary more than 4-fold across regions. Shouldn’t we expect that more cardiologists would be found in regions with higher AMI rates? We don’t find this.
  • In these 28 day survival models, covariates include the full range of newborn risk, excluding those factors that might be influenced by neonatal intensive care capacity. We find that there is a survival benefit to more Neonatologists, although beyond the second quintile of supply no further benefit is discerned. We don’t know the mechanism of this effect. Should we attempt to remedy this apparent usndersrevice by creating incentives for more Neonatologists to locate in the very low quintile? This ,ay or may not be the most cost-effective strategy.
  • What physician shortage?

    1. 1. What Physician Shortage? An Evidenced-Based Perspective David C. Goodman, MD MS Professor of Pediatrics and of Health Policy The Center for Health Policy Research Dartmouth Medical School Hanover, NH May 2009
    2. 2. Workforce Research at The Center for Health Policy Resarch <ul><li>John Wennberg, MD MPH </li></ul><ul><li>Elliott Fisher, MD MPH </li></ul><ul><li>Sam Finlayson, MD MS </li></ul><ul><li>Chiang-hua Chang, MS </li></ul><ul><li>George Little, MD </li></ul><ul><li>Therese Stukel, PhD </li></ul><ul><li>Jonathan Skinner, PhD </li></ul><ul><li>Julie Bynum, MD </li></ul><ul><li>Scott Shipman, MD MPH </li></ul><ul><li>Douglas Staiger, PhD </li></ul><ul><li>James Weinstein, MD MS </li></ul><ul><li>Dongmei Wang, MS </li></ul><ul><li>Sally Sharp, SM </li></ul><ul><li>Stephanie Raymond </li></ul><ul><li>Phyllis Wright-Slaughter, MHA </li></ul><ul><li>Daniel Gottlieb, MS </li></ul><ul><li>Kristen Bronner, MA </li></ul><ul><li>Megan McAndrews, MBA, MS </li></ul><ul><li>David Bott, PhD </li></ul><ul><li>Stephen Mick, PhD (VCU) </li></ul><ul><li>Jia Lan, MS </li></ul><ul><li>Nancy Marth, MS </li></ul><ul><li>Jon Lurie, MD MS </li></ul><ul><li>Ken Schoendorf, MD MPH (CDC/NCHS) </li></ul><ul><li>The Robert Wood Johnson Foundation </li></ul><ul><li>Mithoefer Center for Rural Surgery </li></ul><ul><li>National Institute on Aging </li></ul><ul><li>Health Resources and Services Administration </li></ul><ul><li>WellPoint Foundation </li></ul><ul><li>Aetna Foundation </li></ul><ul><li>United Health Foundation </li></ul><ul><li>California HealthCare Foundation </li></ul>Collaborators Support
    3. 3. The Workforce Crisis <ul><li>Why do many believe that there is a workforce crisis? </li></ul><ul><li>Would patients benefit from higher physician training rates? </li></ul><ul><li>Should we “interfere” with market forces? </li></ul><ul><li>How should we build our workforce and training programs? </li></ul>
    4. 4. U.S. Workforce Policy: From Surplus to Shortage <ul><li>1997: Surplus of physicians. </li></ul><ul><li>2005: Council on Graduate Medical Education 16th report declares an impending physician shortage. </li></ul><ul><li>2006: AAMC recommends 30% increase in medical school enrollment and lifting of the Medicare GME funding cap. </li></ul>
    5. 5. Physician Training - 2000 US Medical Grads ~16,000 per yr Graduate Med Education entry = ~22,000 per yr Clinical Practice International Medical Grads ~6,000 per year Increase Graduate Medical Education Medicare GME: ~$8 billion plus Medicaid $$ Increase US Medical School Enrollment Total Revenue $~60 billion less care/research $~19 b
    6. 6. What is the evidence for an impending shortage? <ul><li>Growing population, particularly of the elderly. </li></ul><ul><li>Increases in age-specific utilization rates. </li></ul><ul><li>Economic expansion: “GDP is destiny”. </li></ul><ul><li>In other words, “demand” is increasingly rapidly; failing to anticipate “demand” with more physicians will lead to a shortage. </li></ul>
    7. 7. AAMC Projected National Supply & Shortfall of Physicians with GME Expansion Source: Salsberg. International Medical Workforce Meeting. 2008. Baseline Supply Additional Supply from Robust GME Expansion Shortfall How large is the shortfall?
    8. 8. AAMC Projected National Supply & Shortfall of Physicians with GME Expansion Source: Salsberg. International Medical Workforce Meeting. 2008. Baseline Supply Additional Supply from Robust GME Expansion Shortfall How large is the shortfall?
    9. 9. The 2020 “Shortfall” in Physicians Council on Graduate Medical Education. Sixteenth Report. 2005. 1,076,000 972,000 1,240,000 1,027,00 1,173,000 1,086,000 Physician Supply, Demand, and Need in the U.S. 2020 “ Shortfall” = ~90,000 or ~10%
    10. 10. An alternative approach: What are the desirable outcomes of investing in the medical workforce? <ul><li>Access: to care when it is wanted and needed. </li></ul><ul><li>Quality: Care that is technically excellent and personally compassionate. </li></ul><ul><li>Outcomes: Care that improves the health and well being of patients and populations. </li></ul><ul><li>Costs: Care that is affordable to the patient and to society. </li></ul>
    11. 11. If we agree on the desirable outcomes... Then the question is: What are the most effective and efficient ways to achieve these ends?
    12. 12. <ul><li>Is there evidence that access, quality, and outcomes are sensitive to physician supply, per se? </li></ul>
    13. 13. www.dartmouthatlas.org John Wennberg Lead Author Co-authors: Elliott Fisher, MD MPH David Goodman, MD MS Jonathan Skinner, PhD
    14. 14. The Per Capita Supply of Physicians Varies ~200% Across Regions Post-GME clinicians per 100K population age sex adjusted - 2005 Dartmouth Atlas Hospital Referral Regions Specialists Generalists 50 75 100 125 150 175 200 225 10% 200% 40 50 60 70 80 90 100 110 120
    15. 15. Clinically Active Physicians per 100,000 Residents by Hospital Referral Region (2005), age-sex adjusted 215 to 316 (57) 200 to < 215 (54) 185 to < 200 (63) 170 to < 185 (67) 118 to < 170 (65) Not Populated
    16. 16. Regional variation in physician supply is not explained by: <ul><li>Patient health status or health risk Chan R, et al. Pediatrics 1997. Goodman D, et al. Pediatrics 2001. Wennberg J. Ed. Dartmouth Atlas of Health Care . Various editions. 1996 - 2006. Fisher E, et al. Ann Int Med 2003. </li></ul>
    17. 17.  Neonatologists * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 0 5 10 15 20 25 30 4 5 6 7 8 9 10 11 12 13 Percent Low Birth Weight Neonatologists per 10,000 births R 2 =0.04 Goodman, et al. Pediatrics , 2001. Are neonatologists located where newborn needs are greater? (246 Neonatal Intensive Care Regions) There is virtually no relationship between regional physician supply and health needs.
    18. 18. Source: Wennberg, et al. Dartmouth Cardiovascular Atlas There is virtually no relationship between regional physician supply and health needs. Are cardiologists located where cardiac needs are greater? (306 Hospital Referral Regions, Dartmouth Atlas) 2.0 4.0 6.0 8.0 10.0 12.0 3.0 6.0 9.0 12.0 15.0 18.0 Acute Myocardial Infarction Rate per 1,000 Medicare Enrollees Cardiologists per 100K
    19. 19. Regional variation in physician supply is not explained by: <ul><li>Patient health status or health risk </li></ul><ul><li>Patients preference for care Fisher E, et al. Ann Int Med 2003. NIA-CMS beneficiary survey, forthcoming. </li></ul>No difference in preferences for aggressive care (dying in hospital, mechanical ventilation, or drugs that would lengthen their life, but make them feel worse) No differences in concerns about getting too little (or too much) treatment
    20. 20. So what? Despite the idiosyncratic location of physicians... maybe more physicians leads to better health outcome.
    21. 21. Do areas with higher physician supply have better health outcomes? Source: Goodman, Fisher, et al. New Engl J Med, 2002. <ul><li>Logistic models 1995 US birth cohort </li></ul><ul><li>N = 3.8 million live births </li></ul><ul><li>Dependent variable: 28 day mortality </li></ul>Very Low Low Medium High Very High 0.8 0.9 1 1.1 Mortality Adj.Odds Ratio Quintile of Physician Capacity in Neonatal Intensive Care Regions Neonatologists Better Outcomes Inefficient Care Beyond a very low supply, outcomes are insensitive to physician supply.
    22. 22. With Similar Outcomes, Many Health Care Systems Deliver Care with Far Fewer Physicians Standardized Physician Labor Input During Last 6 Months of Life Among Medicare Cohorts (Full Time Equivalents per 1,000 beneficiaries) Source: Goodman, Wennberg, Chang, Health Affairs,March/April 2006. Mean Age Total FTEs Primary Care Medical Specialists NYU Medical Center 82 28.3 8.8 15.0 RWJ University Hospital (NJ) 80 19.8 4.3 12.2 Montefiore Med Center (NY) 83 16.5 6.5 7.1 MA General Hospital 80 15.3 6.3 5.5 Johns Hopkins Hospital 77 12.2 5.0 3.9 Yale-New Haven 82 10.6 3.4 4.4 UC, San Francisco 81 9.4 4.7 3.2 Mayo, Rochester MN 81 8.9 3.0 3.9 Strong Memor., Rochester,NY 81 8.1 3.8 2.4
    23. 23. FTE Primary Care Physician Labor Inputs per 1,000 Decedents During the Last Two Years of Life Cedars-Sinai Med Ctr 14.6 NYU Medical Center 13.2 Mass General 11.5 Elliot Hospital 9.8 Fletcher Allen 8.1 Catholic Med Center 7.7 Maine Medical Center 7.0 Mayo Clinic (St. Mary's) 6.8 Dartmouth-Hitchcock 6.5 3.0 7.0 11.0 15.0 19.0 23.0 FTE primary care labor inputs per 1,000
    24. 24. FTE Medical Specialist Labor Inputs per 1,000 Decedents During the Last Two Years of Life Cedars-Sinai Med Ctr 31.6 NYU Medical Center 30.1 Mass General 11.7 Maine Medical Center 10.0 Mayo Clinic (St. Mary's) 8.9 Fletcher Allen 8.8 Elliot Hospital 7.7 Catholic Med Center 6.9 Dartmouth-Hitchcock 6.9 4.0 8.0 12.0 16.0 20.0 24.0 28.0 32.0 FTE medical specialist labor inputs per 1,000
    25. 25. Are Technical Quality and Patient Satisfaction Better with More Physicians? Goodman DC, Fisher ES. New England J Med, 2008. Physicians Per Capita Lowest Quintile Highest Quintile Ratio highest to lowest Total physicians per capita by Hospital Referral Regions (2005) 169.4 271.8 1.60 CMS Compare Composite Scores (2005) Acute myocardial infarction 91.0 93.1 1.02 Congestive heart failure 84.1 88.6 1.05 Pneumonia 79.5 79.2 1.00
    26. 26. Are Technical Quality and Patient Satisfaction Better with More Physicians? Goodman DC, Fisher ES. New England J Med, 2008. Physicians Per Capita Lowest Quintile Highest Quintile Ratio highest to lowest Total physicians per capita by Hospital Referral Regions (2005) 169.4 271.8 1.60 CMS Compare Composite Scores (2005) Acute myocardial infarction 91.0 93.1 1.02 Congestive heart failure 84.1 88.6 1.05 Pneumonia 79.5 79.2 1.00 Medicare access and satisfaction (2005) Ever had a problem and didn't see a doctor? (% No) 91.7 93.2 1.02 Do you have a particular place for medical care? (% Yes) 95.0 95.5 1.01 Satisfied with ease of getting to the doctor? (% Yes) 94.9 94.7 1.00 Satisfied with doctor's concern for overall health? (% Yes) 95.5 95.7 1.00 Satisfied with quality of medical care? (% Yes) 96.7 97.0 1.00
    27. 27. Why is there such a weak association between workforce supply and outcomes?
    28. 28. Examples of Medical Decision Uncertainty that Lead to Different Labor Demand <ul><li>84 y.o with mild CHF, diabetes, and new onset back pain that is poorly controlled with oral opiates. </li></ul><ul><ul><li>Admit to the hospital? </li></ul></ul><ul><li>69 y.o with COPD (Nighttime O 2 ) and two recent episodes of bronchitis with ER visits. </li></ul><ul><ul><li>Consultation with a pulmonologist? Revisit every 2, 4, 6 months? </li></ul></ul><ul><li>65 y.o. with new lumbar disc herniation. </li></ul>
    29. 29. Inpatient back surgery per 1,000 Medicare enrollees (2005) 1.0 3.0 5.0 7.0 9.0 11.0 Back surgery per 1,000 enrollees Minneapolis 5.0 Binghamton 4.4 Rochester 3.8 Buffalo 3.3 Syracuse 3.2 White Plains 2.7 Elmira 2.6 Albany 2.6 Miami 2.4 Manhattan 1.9 East Long Island 1.9 Bronx 1.8
    30. 30. So what? Yes, physician are located idiosyncratically. And maybe outcomes aren’t sensitive to physician supply. Still, would an increase in physician training rates cause any harm?
    31. 31. High Physician Supply/Cost Regions: <ul><li>Less likely to provide primary care. </li></ul><ul><li>Lower perceived access by patients. </li></ul><ul><li>No better patient satisfaction. </li></ul><ul><li>Worse technical quality. </li></ul><ul><li>No better, and sometimes worse outcomes </li></ul><ul><li>Physicians perceive care to be less available, less able to provide quality care. </li></ul>Sirovich B, et al. Ann Int Med 2006. Sirovich B, et al. Arch Int Med 2005. Wennberg J. Ed. Dartmouth Atlas of Health Care . Various editions. 1996 - 2006. Fisher E, et al. Ann Int Med 2003; Fisher E, at al. Health Affairs 2004; Fisher E, et al. Health Affairs 2005. Goodman D, et al. Health Affairs 2006.
    32. 32. Where do more physicians go? Number of Atlas Regions by Physicians per 100,000 population Source: Goodman. Health Affairs, 2004. For every physician that settled in a low supply region, 4 physicians settled in a high supply region. These are the regions associated with lower quality and higher costs. Number of Regions 1979 1999 Number of Atlas Regions by Physicians per 100,000 population
    33. 33. What about the costs of expanding medical schools and removing the Medicare GME funding cap? No published estimates... probably an additional $5-10 billion per annum in training costs. (NIH ~ $28 billion; CDC ~ $8 billion)
    34. 34. Medicare Costs and Non-Interest Income by Source as a Percent of GDP % GDP 2019 Part A trust fund goes broke Part B and D premiums soar
    35. 35. Where would you invest $5-10 billion per annum of public money in the health care system? <ul><li>Implementation of the U.S. Preventive Services Task Force recommendations. </li></ul><ul><li>Greater implementation of Cochrane Collaboration recommendations. </li></ul><ul><li>Increasing NIH funding. </li></ul><ul><li>Rewarding health care systems for improved outcomes. </li></ul><ul><li>Expanding insurance coverage to children (S-CHIP). </li></ul><ul><li>Increasing physician training rates? </li></ul>
    36. 36. Since when did we start trusting market forces to deliver good health care?
    37. 37. Does “Demand” Equal Consumer “Wants?” <ul><li>Consumers can judge quality. (e.g. Consumers Report) </li></ul><ul><li>Lot’s of sellers. </li></ul><ul><li>Consumers are the sole decider. </li></ul><ul><li>Consumers pay the full price (no subsidization). </li></ul><ul><li>Demand = what consumers want. </li></ul><ul><li>Markets work well. </li></ul><ul><li>Evidence-base is imperfect. </li></ul><ul><li>Patients do not have full information. </li></ul><ul><li>There are fewer “sellers.” </li></ul><ul><li>Patients look to physicians to make recommendations. </li></ul><ul><li>Insurers pay the price at the time of the “purchase” decision. </li></ul><ul><li>Demand = utilization </li></ul><ul><li>Market failure. </li></ul>Autos Medical Care
    38. 38. Market forces are like gravity... Each help you get where you want to go, but you wouldn’t want to throw away the steering wheel and brakes.
    39. 39. Restoring Accountability to Health Workforce Planning <ul><li>Decisions about numbers and specialty mix of physician training are left to each training hospital. </li></ul><ul><li>Council on Graduate Medical Education has a narrow policy brief (i.e. physician training only, no dedicated staff) and consists entirely of physicians, primarily from teaching hospitals. </li></ul><ul><li>Public dollars pays for most medical training. </li></ul><ul><li>Permanent Health Workforce Commission </li></ul><ul><ul><li>Public interests and workforce goals should be clearly stated. </li></ul></ul><ul><ul><li>Broad membership (nurses, public health expts., patients, docs) </li></ul></ul><ul><ul><li>Should advice on health workforce, not just physician workforce. </li></ul></ul><ul><ul><li>Dedicated staff support </li></ul></ul><ul><ul><li>Increasingly regulatory responsibility to insulate the deliberations from training program and provider self-interests. </li></ul></ul>Source: Goodman DC. JAMA, September 10, 2008.
    40. 40. Beyond the workforce “crisis” <ul><li>Physician supply varies 2 - 3 fold, generally without differences in outcomes (health status, quality, access, satisfaction). </li></ul><ul><li>Health care systems are adaptable to varying levels of physician supply. </li></ul><ul><li>Expansion of physician training will be costly, and could exacerbate many of our current health care ills. </li></ul><ul><li>Workforce planning in the U.S. lacks coordination and depends on the individual decisions of hundreds of teaching hospitals. </li></ul><ul><li>Physician training resources should be redirected towards health systems delivering efficient care, and preference-based care. </li></ul><ul><li>A robust primary care workforce is necessary but not sufficient for improved systems of care. </li></ul><ul><li>The medical home can only succeed with payment reform and redesign of health care systems to integrated delivery systems. </li></ul>

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