Transcript Document

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
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
AAMC’s 2006 Workforce Position
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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
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
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
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
The Evidence of a Likely
Physician Shortage is Growing
Recent Specialty Specific Reports of Shortages
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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
Recent State Reports Related to Shortages
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•
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Arizona
California
Georgia
Kentucky
Massachusetts
Michigan
Mississippi
Nevada
North Carolina
Oregon
Texas
Wisconsin
Prepared by AAMC Center for Workforce Studies
Unmet Need Already Exists--30 million People
Live in Federally Designated Shortage Areas
Source: HRSA/AAFP
Key Factors Influencing Future Demand
for Physician Services
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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 ↓
Number of Americans Over 65 will Grow by 35
Million Between 2000 - 2030
80,000
70,000
60,000
50,000
65+: 104% increase
from 2000 to 2030
40,000
30,000
20,000
10,000
85+: 127% increase
from 2000 to 2030
0
2000
2010
2020
Source: U.S. Census; Prepared by AAMC Center for Workforce Studies
2030
The Eleven Most Costly Medical Conditions Are Far
More Prevalent Among the Elderly, US 2000
Condition
Treated Prevalence
per 100,000
Spending (millions
of dollars)
Heart disease
6,226
56,700
9%
Trauma
12,338
41,100
7%
Cancer
3,348
38,900
6%
Pulmonary conditions
15,526
36,500
6%
Mental disorders
8,575
34,400
5%
Hypertension
11,382
23,400
4%
Diabetes
4,260
18,300
3%
Arthritis
6,966
17,700
3%
Back problems
5,092
17,500
3%
Cerebrovascular
disease
Pneumonia
854
15,000
2%
1,370
12,600
2%
312,000
50%
Total
Source: Thorpe, K.E., C.S. Florence, & P. Joski (2004)
Prepared by AAMC Center for Workforce Studies
% in total health
care spending
Age-Specific Cancer Incidence Rates/100,000, 2000
3,500
2806
3,000
2,500
2,000
Male
1,500
Female
1,000
500
146
0
<1
1-4
5-9
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84
Age Group
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
85+
Utilization of Physician Services Rise with Age
and Over Time
Ambulatory Care Visits to Physician Offices and Clinics
Average Number of Visits per User
8
7
1980
2000
6
1990
2004
5
4
3
2
1
0
Under 5
5-14
15-24
25-34
35-44
45-54
Age
Source: NAMCS 1980, 1990, 2000 & 2004
Prepared by AAMC Center for Workforce Studies
55-64
65-74
75-84
85 and
over
Factors Influencing Future Supply
• Medical school production (MD, DO)
Total
Numbers
• 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)
Impacts
“effective”
supply
250
231
224
(In thousands)
Number of Physicians
The Physician Workforce is Aging:
250,000 Active Physicians are Over 55
1985
2005
200
150
133
139
153
146
99
94
100
73
44
50
0
Under 35
35-44
45-54
55-64
65 and Over
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
Physician Retirements Will Grow
Rapidly Over the Next 20 Years
30,000
New Physicians
25,000
20,000
Retirements/Departures
15,000
10,000
5,000
0
2000
2005
2010
Prepared by AAMC Center for Workforce Studies, May 2006
2015
2020
2025
The Percent of Physicians That are
Female Is Rising Steadily
50%
MD Graduates: Percent Female
40%
42%
44%
45%
46%
47%
27%
28%
29%
39%
34%
30%
29%
20%
23%
23%
24%
20%
10%
13%
Patient Care MDs:
Percent Female
15%
10%
0%
1980
1985 1990
1995
Source: AAMC Facts; AMA PCD 2006 Edition.
Prepared by AAMC Center for Workforce Studies, Jan 2006
2000 2002
2003 2004
2005
International Medical School Graduates (IMGs):
Why the Concern Now?

International concern about brain drain from lessdeveloped 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.
First-Year Enrollment at Osteopathic Schools May
be as High as 5,700 by 2015
High: +5,702
(85% increase)
6,000
Pr ojec ted
5,000
Low : +4,982
(62% increase)
3,079
(2002-03)
4,000
3,000
Actual
2,000
1,000
1992-93
1994-95
1996-97
1998-99
2000-01
2002-03
2004-05
2006-07
Note: Percent Increase from 2002-03
Source: Osteopathic Workforce Summit, January 2006
Prepared by AAMC Center for Workforce Studies, February 2006, preliminary projections
2008-09
2010-11
2012-13
2014-15
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
7.5
7.3
6.8
7
6.5
6.4
6.5
6.2
6.1
5.8
6
6.4
5.8
5.8
5.5
5.8
5.6
5.6
No Change in Allopathic Matriculants
5.4
5
5.2
15% Increase in Allopathic Matriculants
based on 2003 Enrollment
5
30% Increase in Allopathic Matriculants
based on 2003 Enrollment
4.5
4
1980
1985
1990
1995
Source: AAMC Data Book; US Census Bureau.
Prepared by Center for Workforce Studies, AAMC, Feb 2006.
2000
2005
2010
2015
2020
US MDs Are Less Than 2/3 of Physicians Entering
Graduate Medical Education, 2005
24,735* entered in ACGME and AOA training in 2005:
Other
17 (0.1%)
IMGs
6,436 (26%)
(US IMGs 1,462)
Allopathic Graduates
Canadian Graduates
15,329 (62%)
65 (0.3%)
Osteopathic
Graduates
2,888+ (12%)
(Osteopathic Graduates
in ACGME Training 1,478)
* 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
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.
Active Physicians per 100,000 Pop 2005 –2030
With and Without an Increase in MD Enrollment
300
295
290
285
280
275
30% Increase
270
15% Increase
265
No Increase
260
255
2005
2007
2009
2011
2013
2015
Includes residents and fellows.
Prepared by Center for Workforce Studies, AAMC, Mar 2006.
2017
2019
2021
2023
2025
2027
2029
Challenges to
US Medical School Expansion
Allopathic Schools Plans to Increase First-Year
Enrollment Between 2005 and 2011
Results of 2005 Survey of Deans (116 of 125 schools)
Definitely Not
10% (12)
Not Sure
1% (1)
Definitely or
Already Increased
24% (28)
Probably Not
33% (38)
Probably
16% (19)
Possibly
16% (18)
Projected First-Year Enrollment at Allopathic Schools
Through 2016 Preliminary Estimates
20, 000
19, 000
High (18,453,
12% increase)
18, 000
Low (17,912,
9% increase)
Projec t ed
16,448
(2002-03))
17, 000
Ac t ual
16, 000
15, 000
1992-93
1994-95
1996-97
1998-99
2000-01
2002-03
2004-05
2006-07
Sources: AAMC Data Book (2006) and 2005 AAMC Medical School Enrollment Survey
Prepared by AAMC Center for Workforce Studies, February 2006
2008-09
2010-11
2012-13
2014-15
Potential Barriers to Enrollment Expansion: Percent
of Medical Schools Indicating a "Major" or "Very
Significant" Problem, 2005 Survey
100%
80%
60%
50%
45%
44%
36%
40%
32%
32%
Lim ited
am bulatory
preceptors
Lim ited clinical
training sites
20%
0%
Available
scholarships
for students
Costs of
expansion
Lim ited
classroom
space
Source: 2005 AAMC Medical School Enrollment Survey
Prepared by AAMC Center for Workforce Studies, February 2006
Lim ited lab
space
Growth of Physicians in ACGME
Training Programs, 1995-2006
Total ACGME Residents*
IMGs Entering GME +
1995-96
98,035
5,410
1,843
1996-97
98,076
5,379
1,932
1997-98
98,143
5,414
2,009
1998-99
97,383
5,371
2,096
1999-00
97,989
5,905
2,169
2000-01
96,806
6,097
2 279
(1,242)
2001-02
96,410
6,170
2 510
(1,304)
2002-03
98,258
6,208
2,635
(1,287)
2003-04
99,964
6,004
2,607
(1,473)
2004-05
101,291
6,122
6,436
2,756
(1,535)
2,888
(1,478)
2005-06
Change (‘96 –
2006)
103,106
+5,071(+5.2%)
+1026 (+19%)
DO Grads/(Entering ACGME)
+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
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
The US Has a Relatively Low Supply of Physicians
Compared to other Developed Countries
Physicians Per 100,000 (2000)
Greece
Italy
Belgium
Austria
Slovak Republic
Switzerland
Denmark
France
Spain
Germany
Portugal
Sweden
United States
Australia
New zealand
Ireland
Canada
United Kingdom
Japan
Korea
448
405
386
383
368
351
342
329
326
326
318
304
264
244
223
222
210
201
193
130
0
50
100
150
200
Source: The Supply of Physician Services in OECD Countries. OECD, Steven
Simoens & Jeremy Hurst. Health Working Papers. 2006
250
300
350
400
450
500
What Factors Will Influence Retirement?
Source: 2006 AAMC Survey of Physicians Over 50
% “ Important”
Very
Somewhat
Increased regulation of medicine
43%
31%
Stress of practice
42%
37%
Insufficient reimbursement
42%
28%
Decreasing clinical autonomy
38%
31%
Rising malpractice costs
37%
26%
On call responsibility
36%
27%
Lack of professional satisfaction
31%
31%
Interest in pursuits not related to medicine
26%
40%
Personal health issues
22%
26%
Effort to keep clinically current
19%
35%
Increased family responsibilities
14%
26%
Recertification requirements
13%
26%
Increasing competition in specialty
8%
22%
Occupational safety issues
6%
18%
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
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?
The Growing PA Workforce
Clinically Active PAs Have Nearly Tripled in
the Past 15 Years (in thousands)
60
(in thousands)
50
40
30
21 22
23 25
27 29
31 34
38
40 43
46
50
55
59
20
10
Year
Estimated Total Number of PAs in Clinical Practice at Year-end
Source: American Academy of Physician Assistants
05
20
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
0
19
Number of PAs
70
4,394
4,394
4,275
3,880
2,837
2,187
Year
Source: American Academy of Physician Assistants
05
20
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
19
93
1,642
92
19
91
5,000
4,500
4,000
3,500
3,000
2,500
2,000 1,329
1,500
1,000
500
0
19
Number of New PA's
The Number of PAs Will Continue to Grow
Rapidly as the Number of New Graduates Per
Year Has Tripled in the Past 15 Years
Percent New PAs Going into Generalist
Specialties Decreased Over Past 15 yrs While
Sub-specialists Have Increased
8%
IM Sub
Surg Spec
6%
4%
2%
Other
Ped Sub
Generalists Decreasing
0%
EM
-2%
-4%
IM
FP
Specialists Increasing
Peds
-6%
-8% Gen Surg
*PAs graduating in year immediately preceding the census reference year are considered New Graduates.
Sources: AAPA Membership Census Survey, 1991-1995; AAPA Physician Assistant
Census Survey, 1996-2005.
55%
51%
50%
45%
45% 44%
46% 46%
50%
51%
50%
48%
47%
46%
43%
41%
40%
40%
39%
35%
30%
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
% New PAs in Primary Care
Percent of New PAs Going into Primary Care
(IM,Peds,FP) is Decreasing
Year
Source: American Academy of Physician Assistants
Percent of New PAs* Entering Family
Medicine Each Year, 1991-2005
60%
50%
Family Medicine
40%
30%
20%
10%
0%
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
*PAs graduating in year immediately preceding the census reference year are considered New Graduates.
Sources: AAPA Membership Census Survey, 1991-1995; AAPA Physician Assistant
Census Survey, 1996-2005.
The Number of US MDs Entering Family Practice
Through the NRMP Parallels the Rise and Fall of
PAs Going into Family Practice
2,500
2,000
USMD
1,500
1,000
500
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Source: NRMP
Physicians That Regularly Work with NPs/PAs
Agree that it Improves Efficiency and Care
% Agree Use of NPs/PAs
90%
83%
80%
80%
66%
70%
53%
60%
50%
40%
30%
20%
10%
0%
Improves
efficiency
See complex
patients
Improves care
Source: 2006 AAMC Survey of Physicians Under 50 – Preliminary Results
Could be
expanded
The Future
• Team care
• Collaboration on education and training
• Collaboration on policy and program
development
• Collaboration on data collection and analysis
and workforce research