STRATEGIES TO ACHIEVE BALANCE IN THE ... - Europe PMC

STRATEGIES TO ACHIEVE BALANCE IN THE PHYSICIAN WORKFORCE RICHARD A. COOPER MILWAUKEE, WISCONSIN

Issues of physician training and of the characteristics of the physician workforce have been debated for many decades. Over the past two years, the dialog has centered on a single proposal: that half of all US medical graduates should become primary care physicians: the so called "50% solution" (1). This proposal, initially developed by the Committee on Graduate Medical Education (COGME) (2), was incorporated into Congressional bills in both the House and the Senate. However, none of these bills were successful in the 103rd Congress. This allows an opportunity to reexamine the workforce issues, to analyze the data and draw fresh conclusions. To facilitate that process, five fundamental questions will be addressed: (A) how many physicians are there today; (B) how many are needed; (C) how many will be needed in the future; (D) how many are there likely to be in the future; and (E) what will be the future mix of primary care physicians and specialists?

A. How Many Physicians Are There Today? To answer this question, data on the physician workforce for 1992 were obtained from the American Medical Association Masterfile (3). Physicians were segregated into primary care (family medicine/general practice, general internal medicine and general pediatrics) and specialty medicine. There were 571,000 patient-care physicians in 1992 AMA Masterfile, of whom 99,200 were residents and fellows. Of this total number, 217,700 were primary care physicians and 353,300 were specialists (Table 1). To express the size of the primary care and specialty workforces in a way that is more comparable to the manner in which physicians practice, adjustments were made for the work effort of residents (assumed to be 65%) and for the significant portion of time that primary care residents devote to specialty medicine during their training (Table 1). A second adjustment was made to account for the primary care effort of some specialists. In 1992, the workforce of practicing physicians From the Health Policy Institute, Medical College of Wisconsin, Milwaukee, Wisconsin. Address requests for reprints to: 8701 Watertown Plank Road, Milwaukee, WI 53226. 188

BALANCING THE PHYSICIAN WORKFORCE

Work Effort Physician Workforce Work Effort Adjustments Resident General Specialist Net After Adjustments

TABLE 1 Patient Care Workforce, 1992* Specialty Medicine Primary Care 354.0 217.0 -32.1 +30.4 215.3

-2.9 -30.4 320.7

189 Total 571.0

-35.0 536.0

* In thousands.

included 47,300 internal medicine subspecialists, 41,900 other medically-related specialists (such as neurology, dermatology, radiation oncology and emergency medicine) and 30,300 specialists in obstetrics and gynecology. Many of the physicians in these three categories serve as "general specialists," fulfilling the primary care needs of their specialty patients and sometimes serving as general physicians for other patients as well. The Mendenhall Study (4), published in 1979, found that 60% of the time of specialty internists and 80% of the time of obstetrician/gynecologists was spent delivering what is now referred to as primary care. For purposes of assessing current primary care capacity, these numbers were assumed to be 20% for the medical specialties and 40% for obstetrics and gynecology, and the workforce figures were adjusted accordingly (Table 1). Many specialty groups are now beginning to examine their "general specialist" effort. From surveys done by gastroenterologists, cardiologists, neurologists and others, it appears that the 20% figure is not far off. With these adjustments, the total patient care workforce contracts almost 7%, from 571,000 physicians to 536,300 "physician equivalents." The primary care workforce consists of 84 physician equivalents per 100,000 of population, and the specialty workforce of 125/100,000. The total is 209 physicians per 100,000 of population. B. How Many Physicians Are Needed Today? Primary Care Physicians. The US is in the midst of an active, transitional medical market that is moving rapidly to incorporate managed care principles. The managed care sector has created the greatest numerical demand for primary care physicians. Weiner has calculated that health care systems that include predominantly managed care, and that have an abundance of nonphysician providers (NPPs), require roughly 60 FTE primary care physicians per 100,000 of population (5). This serves as a "lower limit." It has been adjusted upward in several ways (Table 2). First, an adjustment was made to translate FTE physicians to individual physicians, recognizing that

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TABLE 2 Physician Demand and Supply, 1992* Primary Care 60 HMO Demand, FTEs# +8 HMO Physicians +4 Community Practice +2 Teaching, Research +6 Women Physicians Non-HMO Specialistst 80 Adjusted Physician Demand 84 Current Supply

Specialty Medicine 85 +11 +10 +6 +8 120 125

* Physicians per 100,000 of population. # HMO requirement extrapolated to entire population (5). t Preventive medicine, public health, occupational medicine, psychiatry.

not all physicians have the same work effort. Some are older, some have certain administrative responsibilities, and some work part time. The cut-off for inclusion as an active physician by the AMA data-base is only 20 hours a week (3). It was assumed that the average practice effort of physicians listed in the AMA Masterfile is 85-90% of a fullyengaged practitioner. This is an important matter that needs further study. The estimate of physician demand derived by Weiner is for a system that operates by the stringent principles of most staff model HMOs. It is not clear that these principles will be broadly accepted, and a further adjustment was made to allow for a standard of practice (the "community standard") that permits a duration and quality of interaction between patients and physicians that both desire (6). A further adjustment was made to account for the significant teaching that primary care physicians do. Finally, an adjustment was made to correct for the reduced work effort of women physicians, who disproportionately choose primary care. These adjustments suggest that a workforce of about 80 primary care physicians per 100,000 of population should be sufficient, assuming they are adequately supplemented with NPPs. This is a gross approximation, a starting point. More work is needed to refine these numbers. Specialists. The "lower limit" of specialists that a system dominated by managed care would utilize is approximately 85 FTEs per 100,000 (5). To allow for variation in the commitment of time to practice among physicians, this was adjusted upward by 10-15% (Table 2). However, Weiner's estimates are for maximally occupied specialists by the standards of managed care. It is not clear that all specialists can or should practice at that level of intensity, and a further upward adjustment of 10% was made. An additional adjustment was made for the large


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number of specialists who devote significant time to teaching and research. Finally, there are specialists who are needed to fill roles that are not represented in HMOs, including the staffing of state mental hospitals or working in fields such as preventive medicine, public health and occupational medicine. They, too, must be counted. When all of these adjustments are made, an estimate for the number of specialists that would be needed today, if the system was predominantly managed care, is 120/100,000 of population. This is a liberal estimate. Some would argue that it's too high, others that it's too low. There are not sufficient good data to draw upon. When these estimates of current demand are compared with the earlier estimates of current physician supply (Table 1), the supply of primary care physicians is in close agreement with the estimated demand. The same appears to be true for specialists, although a small surplus exists. C. How Many Physicians Will Be Needed in the Future? Many uncertainties surround estimates of the future demand for physicians. Some factors suggest that more physicians will be needed. For example, changes in the system may expand access to care, and changes in technology are likely to expand the range of beneficial services. A reduction in the average work effort of physicians would increase the total number of physicians necessary to deliver clinical services. But other factors could decrease the need for physicians. The most profound of these is an increase in the number of NPPs (nonphysician providers) and others capable of undertaking some of the responsibilities now exercised by physicians. Reasonable estimates indicate that the number of NPPs will double over the next 15 years, reaching almost 300,000 (7,8). States are giving more independent prerogatives to them, and they are becoming a significant factor in the equation. Their role in relation to the role of physicians will need to be defined. It is unlikely that the health care system of the future will demand physician services for what can competently and economically be provided by NPPs. Ultimately, the number of physicians that will be needed in the future will depend on what it is that physicians will do. Primary Care Physicians. The principal factor driving the need for primary care physicians is demographics. Primary care is populationbased. In per capita terms, the number of primary care physicians has been relatively constant for more than four decades (Figure 1). Changes in demographics related to enhanced access to care and to

RICHARD A. COOPER

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YEAR FIG. 1. Physician Demand Projections. The supply of primary care physicians from 1950 to 1992 is depicted by the solid lines. The dashed line represents an extrapolation of the present rate of increase in the number of specialists. Interrupted lines denote projected physician demand, as described in the text.

aging of the population will call for more primary care physicians. A figure of 85/100,000 is a good first approximation. Specialists. The guide posts for specialist demand are even less distinct. That is because the specialty workforce is largely technologybased, and the evolution of technology is so unpredictable. Elements of the specialty workforce will expand or contract, depending on how technology advances and how the market embraces these new technologies. Although some technologies replace others, making no further demand on the specialty workforce, most do not; and even those that do frequently enlarge the demand for specialty services. At some point, equilibrium will be reached between the ebb and flow of technology and the necessary size of the specialty workforce, but that is unlikely to occur until well into the 21st century. Specialists have been increasing in numbers at a rate of 3/100,000 of the population annually for the past 30 years. A somewhat lesser rate would have been ideal. If needs over the next 30 years can be met by an increase in the number of specialists at a rate of only 1/100,000, a rate that is only 1/3 of the rate experienced over the past 30 years, the projected need for specialists will slowly grow from 120/100,000 today to 160/100,000 in the 2nd quarter of the next century. This seems to be a modest estimate of future need when one considers the enormous

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progress being made in science and technology and the growth in beneficial services that is likely to result. Both of these estimates of future demand are imprecise and need to be better defined. Within this limitation, they can serve as a reference point against which future physician supply can be examined. D. How Many Physicians Will There Be in the Future? The projected supply of patient care physicians between the years 1992 and 2032 was calculated as reported previously (1), based on the assumption that the influx of new physicians would equal the number of US allopathic and osteopathic medical graduates (USMGs) plus 33% (Figure 2). No adjustment was made for the work effort of residents. This model predicts that the total number of patient care physicians will increase to approximately 850,000 in 2022 and plateau thereafter. A somewhat lower estimate was derived by the Bureau of Health Professions in 1990, when the number of international medical graduates (IMGs) exceeded the number of US graduates by only 30% (2). However, there has been a steep increase in the number of IMGs over the past few years, and both the 1992 projection and that of the Bureau are less than the projection based on the number of IMGs who entered residency in 1994, a record level that is almost 40% of the number of

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YEAR FIG. 2. Projected Supply of Patient Care Physicians. The total number of patient care physicians is projected under four scenarios, each dependent on the number of first year residency positions in excess of the number of US medical graduates. The solid line is the projection based on the experience in 1992, and it was used in subsequent analysis.

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USMGs. If this level continues, the physician workforce will grow to over 900,000. Finally, a curve was constructed assuming that the number of IMGs will be constrained to 110% of the number of USMGs by the year 2000, as proposed by COGME (2) and included in some of the Congressional bills. It should be noted that these models assume that most or all IMGs will remain in the US after they complete training. But the world is changing, and that may not be a fair assumption for the future. To translate these projections of physician supply into physicians per capita requires an understanding of what is likely to happen to the US population over the next 40 years. The Bureau of Census periodically modifies its estimates of the future US population, based on their assumptions regarding birth rate, life expectancy and net immigration. The Census Bureau has tended to increase its estimates over time (Figure 3). In their latest estimate (the 1993 estimate), there was a small but significant increase once again. The data regarding the future physician workforce that are familiar to most physicians are those constructed by the Bureau of Health Professions and used by COGME (2) and others. Unfortunately, the population estimates used in their projections are substantially lower than the current estimates of the Census Bureau, and the data on

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YEAR FIG. 3. US Population Projections. Population estimates are those of the Bureau of Census, as constructed by them in three years: 1990 (the base year used in data constructed for the Council on Graduate Medical Education Third Report by the Bureau of Health Professions) 1992, and 1993 (the population estimates used in the analysis herein).

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physicians per capita that were developed from them are not valid today. When these various population estimates are combined with the projection of physician supply that was constructed from the 1992 data base, two interesting patterns emerge (Figure 4). First, the population figures used in constructing COGME's Third Report create an image of a physician workforce that, in per capita terms, grows progressively over the next three decades. A very different image emerges when current population estimates are used. The pattern created a "turn-ofthe-century bulge"-a rise in physician supply early in the next century followed by a return to levels approaching those that exist today. It is important to recognize that the dynamics that will create the "turn-of-the-century bulge" are all operative already. There is little that we can do to influence them. The training decisions made today will affect the period after the year 2012. This bulge will vary significantly depending on the number of IMGs that enter the workforce. Figure 5 depicts the range of physicians per 100,000 of population under circumstances of first year residency positions ranging from 140% of USMGs to 110%. For comparison, physician demand over this period of time also is plotted. While a near-term surplus seems inevitable, it is not clear that there will be a long-term surplus.

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YEAR FIG. 4. Effect of Population Estimates on Per Capita Physician Supply Projections. Patient care physicians per 100,000 of population are projected, using the physician supply model designated in "133%" in Figure 2 and the various population estimates in Figure 3.

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FIG. 5. Effect of Total Physicians Supply on Per Capita Physician Supply Projections. A range of physician supply projections per capita is shown under conditions varying from first year residents equaled to 110% of the number of US medical graduates (lower limit) to 140% (upper limit). The 1993 population estimates were used. For comparison, the projection of physician demand from Figure 1 is plotted.

What Will Happen to the Primary Care and Specialty Components of the Physician Workforce? Figure 6 presents two scenarios, based on the proportions of medical students that choose primary care and specialty medicine: a slow increase to 33% primary care among the graduates of the year 2003 and a steep rise to a 50%-50% mix by the year 2000. These projections are adjusted for the work effort of residents and for the primary care effort of "general specialists," as described earlier (Table 1). They were calculated from the 1992 base year, a year in which first year residents were 133% of the number of USMGs. Primary Care Physicians. Regardless of the percent of students who choose primary care, only small differences are seen in number of primary care physicians early in the next century under these two scenarios (Figure 6). If 33% of graduates choose primary care, the number of primary care physicians will slowly rise thereafter, largely because the total number of physicians is rising, and it will plateau at about 90/100,000 early in the next century. This seems ideal for the health care environment that is developing. If, instead, the number of students choosing primary care increases to 50% by the year 2000, the number of primary care physicians will grow progressively to almost 120/100,000 in 2032. It seems unlikely

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number of primary care physicians and specialists per 100,000 of population is shown under two training scenarios: (A) 33% of first year residents undertake practice in primary care and 67% in specialty medicine (squares); and (B) 50% of practice specialty medicine and 50% primary care (circles). For comparison, the projected need for physicians from Figure 1 is plotted (triangles).

that an efficient system supplemented with NPPs would be able to use such large numbers of primary care physicians, unless primary care physicians, themselves, begin to specialize, as now is beginning to happen to a limited degree. Thus, no matter what medical students choose to do, the market simply cannot count on new graduates to appreciably increase the supply of primary care physicians over the next ten years. The training decisions made today will have their major effect 15-30 years from now, just as the decisions of the 1970s will have their peak effect after the turn of the century. However, changes in the medical market are occurring already. Compensation for primary care has increased substantially over the last several years, and some specialists are shifting their patient mix to include more primary care. The market also is creating more efficient modes of practice. The most profound consequence of market forces is the increased production of non-physician providers, many of whom are being given more independent prerogatives. All of these dynamics are more rapid and more predictable than the training of new primary care physicians, and all will contribute importantly to meeting current demand. Moreover, all of these factors

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will add primary care capacity and decrease the future demand for new primary care physicians. Specialists. The number of specialists will increase by approximately 20/100,000 over the next decade regardless of what choices medical students make today, because the pipeline is already in place (Figure 6). It is inevitable that a surplus of specialists will exist during the "turn-of-the-century bulge." This reservoir of under-utilized specialists early in the next century represents the major source of physicians to meet the immediate needs in primary care. Decreasing the percentage of graduates entering the specialties to 67% will lead to a plateau of specialists of 150-160/100,000 of population. This approximates the projected demand for specialists in the second quarter of the 21st century. If, instead, the "50% solution" is achieved, the number of specialists will peak at approximately 160/ 100,000 in the first decade of the next century but then fall progressively to levels not experienced since the 1980s. However, over this same period of time science and technology will have progressed enormously, and the need for physicians with special expertise will be substantial. A decrease in the specialty workforce of this magnitude is not consistent with the needs and opportunities that are likely to exist in the technologically-advanced health care system of the future. Thus, both the need for primary care physicians and for specialists will be more than met if 1/3 of medical graduates choose primary care and 2/3 choose specialty medicine. Moreover, in view of the growing enthusiasm for primary care among current medical students, it does not appear that this scenario would be difficult to achieve. The "50% solution" leads to a very different picture. After the "turn of the century bulge" in specialist supply, the number of specialists will plummet, particularly in relation to the projected demand. At the same time, a huge surplus of primary care physicians will develop. Coupled with the simultaneous increase in NPPs, most of whom will be providing primary care services, a serious distortion will exist. CONCLUSION The physician workforce is influenced by a complicated dynamic that has a temporal component. There are two phases to this dynamic. The first is the near-term phase, the phase that spans the next 10 or 15 years, the phase that will be influenced by the confluence of the present workforce with the physicians now in training. The second phase is the long-term phase that begins 15 years from now and


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continues thereafter. It is the phase that will be influenced by today's training decisions. In the first phase there is an apparent demand for more primary care physicians. The magnitude of this need is not well characterized. From data presented above, there does not appear to be a true shortage of primary care physicians. Yet, there is competition for primary care physicians in the marketplace. Much of this is competition among managed care organizations for patients, not for physicians. However, even if there is a true demand that exceeds supply, it is unrealistic to expect that it will be met by the training of new physicians. More immediate relief will come from changes in the practices of current specialists and increases in the number of NPPs. The dominant characteristic of the first phase is the "turn of the century bulge" in specialist supply. An over-abundance exists already, and it will steadily worsen. Unfortunately, most of the physicians who will create this bulge are in practice or in the pipeline already. Specialists will respond to this in a variety of ways. Some will retire early, and some will reduce their work effort. Some will redirect their practices to primary care or other fields. Retraining will be important for many of them. Finding ways to deal with this near-term specialist surplus will be a major element affecting the physician workforce over the next 15 years. The second phase begins 15 years from now and spans the 15 years thereafter. It is the time-frame that will be influenced by the training decisions made today. There is a need to ensure balance between primary care and specialty medicine in this time-frame. A mix of trainees that is 1/3 in primary care and 2/3 in specialty medicine could create that balance. Market forces and other incentives are moving medical student career choices in that direction already, and legislative action to achieve it is both unnecessary and unwise. In contrast, it appears that the "50% solution" will distort this balance. While there are some who feel that this distortion can be averted by subsequent changes in the proportion of graduates training in primary care and specialty medicine, actions taken then will face the same lead-time constraints that are now being faced, as large numbers of specialists enter the workforce at a time when they are not needed. But to some the 50% solution does not create an imbalance. It creates a desirable outcome. It leads to a health care system that relies less on specialists and technology and more on generalists and NPPs; a system that views science as the driver of costs rather than the genesis of cures. It will be difficult to arrive at the proper mix of primary care

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physicians and specialists without first arriving at a consensus regarding the kind of health care system we should have. Finally, there is the issue of the long-term supply of physicians. This is related not simply to medical school enrollment. It also is related to the increasing rate at which IMGs are entering the market, and it is interwoven with the expanding supply of NPPs and other health care workers. The physician workforce cannot be ever-expanding. Many believe that some kind of control will be required at the level of graduate medical education (GME). However, it is inherently difficult to regulate a process when there is a 20 year lag time between the point at which an action is taken and the point at which the consequences of that action are felt. The temporal dimensions and philosophic perspectives that characterize the debate about the necessary size and composition of the physician workforce pose enormous challenges to both policy-makers and physicians as America struggles with the issues of health care reform. 1. 2.

3. 4. 5.

6. 7. 8.

REFERENCES Cooper RA: Seeking a balanced physician workforce for the 21st century. JAMA 1994;272:680-7. Council on Graduate Medical Education: Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century, Washington, DC: US Department of Health and Human Services 1992. American Medical Association: Physician Characteristics and Distribution in the US, Chicago, IL: American Medical Association 1994. Aiken LH, Lewis CE, Craig J, Mendenhall RC, Blendon RJ, Rogers D: The contribution of specialists to the delivery of primary care. NEJM 1979;300:1363-1370. Weiner JP: Forecasting the effects of health reform on US physicians workforce requirements: evidence from HMO staffing patterns. JAMA 1994;272:222-230. Safran DG, Tarlov AR, Rogers WH: Primary care performance in fee-for-service and prepaid health care systems. JAMA 1994;271:1579-1586. DeAngelis CD: Nurse practitioner redux. JAMA 1994;271:868-871. Jones PE, Cawley JF: Physician assistants and health care reform: clinical capabilities, practice activities, and potential roles. JAMA 1994;271:1266-1272.

DISCUSSION Allen, Charleston: I want to be a devil's advocate for just a moment concerning your manpower projections. You didn't have a chance, of course, to explain the assumptions you used in those projections so it is possible that you have taken some of my concerns into consideration. Those concerns include the point that those projections are based upon the assumption that the mechanisms of care delivery will remain as they are now, and as most of us who are in the trenches now are seeing. There is good reason to believe that the way care is implemented is going to change, and that this will have a significant influence upon manpower needs.


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The second point, which is certainly not a popular point from the sociologic point of view, is that the designation of our resources to health care delivery cannot continue to accelerate, especially the proportion which is based primarily upon increased technology as well as probably on profit abuse. The Oregon system, and other systems which are addressing this issue are probably opening salvos which indicate that as unpopular as it may be, some form of rationing of care is going to come about. The format of that rationing will obviously impact society's needs for physicians over the upcoming decade. I wonder if you would mind commenting on those two points, and how they would fit into your model. Cooper: These are two key points. What will happen to the system and how will costs be managed within the system. I guess it will depend on whether the system that we have in the future is driven by the commercial imperative or by a professional imperative. Will it be a system in which physicians as we know them-as highly skilled, highly trained individuals who understand the spectrum of biology and disease-are entrusted with the care of patients? Or will cost considerations drive the system toward less fully trained individuals, a lesser degree of biologic understanding, and even unorthodox and alternative therapies. If we are going to have a highly skilled and highly trained group of individuals providing care within a cost-effective, integrated system of care, that influences the projection of need for physicians significantly. If on the other hand the commercial imperative drives the system to utilize less-skilled individuals, totally different numbers come up. The major question is how do we want to shift the aggregate knowledge base ofthe individuals providing care. If it is to highly skilled individuals, we need quite a few physicians. If it is to those with lesser skills, we won't need very many physicians at all. Levey, Los Angeles: Buz, we didn't have time to go into how you arrived at some of your numbers, but in California the various health maintenance organizations use physicians at a rate of about 111 physicians/100,000 population. If HMOs become the largest compartment for medical care in the United States, which it probably will, physicians will be practicing in a compartment using physicians between 111 and 114/100,000. Whatever is left of the fee for service market, which will have most of the subspecialists, is going to have somewhere in the range of about 340 physicians per 100,000. Earlier projections, including the Bane report, projected an optimal physician: population ratio of 141/100,000. It is going to be hard to reconcile your numbers in this kind of system. Secondly, some make the assumption that we are going to be regulated with regard to the numbers of physicians and the number of procedures permitted. It is not going to be the open market that has driven subspecialty practice. Cooper: First, the minimum numbers that you quote are a starting point, and they are similar to Jonathan Weiner's numbers that we used in analyzing our data. They form a baseline. There isn't time to go through all the assumptions, but one has to begin by translating the baseline number of FTE's into bodies into real physicians. Not all physicians work full-time, and some women work substantially less than full time (you know that 40% of medical school classes are now comprised of women). There are physicians outside of HMO's who supplement HMO physicians, and there are non-HMO practice arrangements. In addition, some physicians serve functions not served by HMOs. The number may not be as high as 200 or 225; but it is substantially above 114. Unfortunately, Jerry, there really isn't a good number, but I wanted to have something out there to form the basis for discussion. Harry Beaty, Northwestern: Buz, I have heard many ofyour assumptions before and I believe I understand them and accept the validity of a lot of what you are saying. You only were able to allude to the issue of the specialist as a primary care physician, and I

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think that is something that is frequently under-represented in the debate about whether or not we need more primary care physicians and exactly how many we need. It is my view that a patient who has breast cancer is better off having primary care provided by the oncologist than by a primary care physician designated by specialty. I'd like you to comment on this as it relates to the numbers that you think we need to work for. Cooper: You are absolutely right. In my earlier comments I said that it may not be wise to make the very sharp distinction between primary care and specialty medicine, both for the reasons you just stated and because specialists themselves are beginning to redefine what constitutes the scope of their particular disciplines. I don't think physicians should be put into a straight jacket of primary care and specialty medicine. We need to allow for a more fluid series of professional relationships.