Transcript Where did all the doctors go?

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
Workforce Research at The Center for Health Policy Resarch
Support
Collaborators
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John Wennberg, MD MPH
Elliott Fisher, MD MPH
Sam Finlayson, MD MS
Chiang-hua Chang, MS
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George Little, MD
Therese Stukel, PhD
Jonathan Skinner, PhD
Julie Bynum, MD
Scott Shipman, MD MPH
Douglas Staiger, PhD
James Weinstein, MD MS
Dongmei Wang, MS
Sally Sharp, SM
Stephanie Raymond
Phyllis Wright-Slaughter, MHA
Daniel Gottlieb, MS
Kristen Bronner, MA
Megan McAndrews, MBA, MS
David Bott, PhD
Stephen Mick, PhD (VCU)
Jia Lan, MS
Nancy Marth, MS
Jon Lurie, MD MS
Ken Schoendorf, MD MPH (CDC/NCHS)
• The Robert Wood Johnson
Foundation
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Mithoefer Center for Rural Surgery
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National Institute on Aging
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Health Resources and Services
Administration
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WellPoint Foundation
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Aetna Foundation
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United Health Foundation
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California HealthCare Foundation
The Workforce Crisis
• Why do many believe that there is a workforce crisis?
• Would patients benefit from higher physician training
rates?
• Should we “interfere” with market forces?
• How should we build our workforce and training
programs?
U.S. Workforce Policy: From Surplus to Shortage
• 1997: Surplus of physicians.
• 2005: Council on Graduate Medical Education 16th report declares an
impending physician shortage.
• 2006: AAMC recommends 30% increase in medical school enrollment
and lifting of the Medicare GME funding cap.
Physician Training - 2000
International Medical Grads
~6,000 per year
Total Revenue $~60 billion
less care/research $~19 b
US Medical Grads
~16,000 per yr
Increase
US Medical School
Enrollment
Medicare GME: ~$8 billion
plus Medicaid $$
Graduate Med Education
entry = ~22,000 per yr
Increase
Graduate Medical
Education
Clinical
Practice
What is the evidence for an impending shortage?
• Growing population, particularly of the elderly.
• Increases in age-specific utilization rates.
• Economic expansion: “GDP is destiny”.
• In other words, “demand” is increasingly rapidly;
failing to anticipate “demand” with more physicians
will lead to a shortage.
AAMC Projected National Supply &
Shortfall of Physicians with GME Expansion
How large is the
shortfall?
Shortfall
Additional
Supply from
Robust GME Expansion
Baseline Supply
Source: Salsberg. International Medical Workforce Meeting. 2008.
AAMC Projected National Supply & Shortfall
of Physicians with GME Expansion
Shortfall
Additional Supply from Robust GME Expansion
Baseline Supply
Source: Salsberg. International Medical Workforce Meeting. 2008.
How large is the
shortfall?
The 2020 “Shortfall” in Physicians
Physician Supply, Demand, and Need in the U.S. 2020
1,400,000
1,240,000
1,173,000
1,200,000
1,076,000
1,086,000
1,000,000
1,027,00
972,000
800,000
“Shortfall” = ~90,000 or ~10%
600,000
400,000
200,000
0
Supply
Demand
Council on Graduate Medical Education. Sixteenth Report. 2005.
Need
An alternative approach:
What are the desirable outcomes of investing
in the medical workforce?
• Access:
to care when it is wanted and needed.
• Quality:
Care that is technically excellent and personally
compassionate.
• Outcomes:
Care that improves the health and well being of patients
and populations.
• Costs:
Care that is affordable to the patient and to society.
If we agree on the desirable outcomes...
Then the question is:
What are the most effective and efficient ways to
achieve these ends?
Is there evidence that access,
quality, and outcomes are sensitive
to physician supply, per se?
www.dartmouthatlas.org
John Wennberg
Lead Author
Co-authors:
Elliott Fisher, MD MPH
David Goodman, MD MS
Jonathan Skinner, PhD
The Per Capita Supply of Physicians
Varies ~200% Across Regions
Specialists
225
120
110
200
100
175
90
150
200%
125
10%
100
Generalists
80
70
60
75
50
50
40
Dartmouth Atlas Hospital Referral Regions
Post-GME clinicians per 100K population age sex adjusted - 2005
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
Regional variation in physician supply is not explained by:
• 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.
Are neonatologists located where newborn
needs are greater?
(246 Neonatal Intensive Care Regions)
Neonatologists
Neonatologists
per 10,000 births
30
R2=0.04 *
25
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20
*
*
*
15
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10
5
0
4
5
6
7
8
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9 10 11 12 13
Percent Low Birth Weight
Goodman, et al. Pediatrics, 2001.
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)
Cardiologists per 100K
12.0
10.0
There is virtually no
relationship between regional
physician supply and health
needs.
8.0
6.0
4.0
2.0
3.0
6.0
9.0
12.0
15.0
Acute Myocardial Infarction
Rate per 1,000 Medicare Enrollees
Source: Wennberg, et al. Dartmouth Cardiovascular Atlas
18.0
Regional variation in physician supply is not explained
by:
• Patient health status or health risk
• Patients preference for care
Fisher E, et al. Ann Int Med 2003.
NIA-CMS beneficiary survey, forthcoming.
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
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?
Mortality
Adj.Odds Ratio
• Logistic models 1995 US
birth cohort
1.1
Better
Outcomes
Inefficient Care
• N = 3.8 million live births
• Dependent variable:
28 day mortality
1
0.9
0.8
Very Low
Low
Medium
High Very High
Quintile of Physician Capacity in
Neonatal Intensive Care Regions
Neonatologists
Source: Goodman, Fisher, et al. New Engl J Med, 2002.
Beyond a very low
supply, outcomes are
insensitive to physician
supply.
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)
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
Source: Goodman, Wennberg, Chang, Health Affairs,March/April 2006.
FTE Primary Care Physician Labor Inputs per 1,000 Decedents
During the Last Two Years of Life
FTE primary care labor inputs per 1,000
23.0
19.0
15.0
11.0
7.0
3.0
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
FTE Medical Specialist Labor Inputs per 1,000 Decedents
During the Last Two Years of Life
FTE medical specialist labor inputs per 1,000
32.0
28.0
24.0
20.0
16.0
12.0
8.0
4.0
Cedars-Sinai Med Ctr
NYU Medical Center
Mass General
Maine Medical Center
Mayo Clinic (St. Mary's)
Fletcher Allen
Elliot Hospital
Catholic Med Center
Dartmouth-Hitchcock
31.6
30.1
11.7
10.0
8.9
8.8
7.7
6.9
6.9
Are Technical Quality and Patient Satisfaction Better
with More Physicians?
Physicians Per Capita
Lowest
Quintile
Highest
Quintile
Ratio
highest to
lowest
169.4
271.8
1.60
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
Total physicians per capita by Hospital Referral Regions
(2005)
CMS Compare Composite Scores (2005)
Goodman DC, Fisher ES. New England J Med, 2008.
Are Technical Quality and Patient Satisfaction Better
with More Physicians?
Physicians Per Capita
Lowest
Quintile
Highest
Quintile
Ratio
highest to
lowest
169.4
271.8
1.60
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
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
Total physicians per capita by Hospital Referral Regions
(2005)
CMS Compare Composite Scores (2005)
Medicare access and satisfaction (2005)
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
• 84 y.o with mild CHF, diabetes, and new onset back pain that is poorly
controlled with oral opiates.
– Admit to the hospital?
• 69 y.o with COPD (Nighttime O2) and two recent episodes of bronchitis
with ER visits.
– Consultation with a pulmonologist? Revisit every 2, 4, 6 months?
• 65 y.o. with new lumbar disc herniation.
Inpatient back surgery per 1,000 Medicare
enrollees (2005)
Back surgery per 1,000 enrollees
11.0
9.0
7.0
5.0
3.0
1.0
Minneapolis
Binghamton
Rochester
Buffalo
Syracuse
White Plains
Elmira
Albany
Miami
Manhattan
East Long Island
Bronx
5.0
4.4
3.8
3.3
3.2
2.7
2.6
2.6
2.4
1.9
1.9
1.8
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?
High Physician Supply/Cost Regions:
• Less likely to provide primary care.
• Lower perceived access by patients.
• No better patient satisfaction.
• Worse technical quality.
• No better, and sometimes worse outcomes
• Physicians perceive care to be less available, less able to provide
quality care.
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.
Where do more physicians go?
Number of Regions
1979
Number of Atlas Regions by
Physicians per 100,000 population
1999
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.
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)
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
Where would you invest $5-10 billion per annum of
public money in the health care system?
• Implementation of the U.S. Preventive Services Task Force
recommendations.
• Greater implementation of Cochrane Collaboration
recommendations.
• Increasing NIH funding.
• Rewarding health care systems for improved outcomes.
• Expanding insurance coverage to children (S-CHIP).
• Increasing physician training rates?
Since when did we
start trusting market
forces to deliver
good health care?
Does “Demand” Equal Consumer “Wants?”
Medical Care
Autos
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Consumers can judge quality.
(e.g. Consumers Report)
Lot’s of sellers.
Consumers are the sole decider.
Consumers pay the full price (no
subsidization).
Demand = what consumers want.
Markets work well.
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Evidence-base is imperfect.
Patients do not have full information.
There are fewer “sellers.”
Patients look to physicians to make
recommendations.
Insurers pay the price at the time of
the “purchase” decision.
Demand = utilization
Market failure.
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.
Restoring Accountability to
Health Workforce Planning
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Decisions about numbers and specialty mix of physician training are left
to each training hospital.
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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.
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Public dollars pays for most medical training.
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Permanent Health Workforce Commission
– Public interests and workforce goals should be clearly stated.
– Broad membership (nurses, public health expts., patients, docs)
– Should advice on health workforce, not just physician workforce.
– Dedicated staff support
– Increasingly regulatory responsibility to insulate the deliberations from
training program and provider self-interests.
Source: Goodman DC. JAMA, September 10, 2008.
Beyond the workforce “crisis”
• Physician supply varies 2 - 3 fold, generally without differences in
outcomes (health status, quality, access, satisfaction).
• Health care systems are adaptable to varying levels of physician
supply.
• Expansion of physician training will be costly, and could
exacerbate many of our current health care ills.
• Workforce planning in the U.S. lacks coordination and depends
on the individual decisions of hundreds of teaching hospitals.
• Physician training resources should be redirected towards health
systems delivering efficient care, and preference-based care.
• A robust primary care workforce is necessary but not sufficient for
improved systems of care.
• The medical home can only succeed with payment reform and
redesign of health care systems to integrated delivery systems.