Physician Workforce Policy Guidelines for the United States,...

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Title: Physician Workforce Policy Guidelines for the United States, 2000-2020
Author: The Council on Graduate Medical Education
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Summary and Recommendations
The Council on Graduate Medical Education (COGME) assessed the likely future supply, demand, and need for physicians in the United States (U.S.) through 2020 for both generalist and non-generalist physicians. The models used for the projections are based on historical patterns of use of services and physician practice patterns applied to the expected U.S. population and the physician workforce through 2020. Where changes are occurring or have occurred in the historic patterns, this report incorporates the best available information and discusses their likely implications. The models used build on the physician forecasting models of the Health Resources and Services Administration (HRSA)/Bureau of Health Professions (BHPr).1 The use of these models helps to ensure some consistency with prior work and facilitates comparisons of the new forecasts with prior forecasts.
Scenarios have been constructed around the best understanding of changes occurring in health care and in medicine. For each scenario, the report presents a sensitivity analysis indicating what the impact might be if that factor were to change to a lesser or greater extent than current understanding portends.
The report forecasts future supply based on the age, gender, specialty distribution, and educational background of the existing supply and current trends in new entrants into residency training from U.S. allopathic and osteopathic schools, from Canadian medical schools, and from foreign medical schools. The report also forecasts future demand and need for physician services based on the historical patterns of use of services by age, gender, insurance status, type of area (urban or rural), and managed care penetration. Estimates of future need are based primarily on the assumption that the use of physician services by the uninsured would increase to the level of those with health insurance if resources were available to meet their needs. It is also assumed that the removal of other barriers to use would also contribute to some increase in service use. Further, the report presents an analysis of supply, demand, and need for generalist and non-generalist specialties.2
This report includes the results of the data analysis and describes methodologies used to forecast supply, demand, and need and the potential impact of changes in the factors that influence each of those. The report also includes recommendations to better assure that the future supply meets future demand and need.
KEY FINDINGS
  1. Under current production and practice patterns, the supply of practicing physicians in the U.S. is expected to rise from 781,200 full-time equivalent (FTE) physicians3 in 2000 to 971,800 in 2020, a 24 percent increase. However, growth is expected to slow considerably after 2010, reflecting increased rates of physician separation due to the aging of the current physician workforce and the relatively level annual number of new physician entrants since 1980. After 2015, the rate of population growth will exceed the rate of growth in the number of physicians. The per capita number of physicians is forecasted to rise from 283 per 100,000 Americans in 2000 to 301 in 2015 but then drop to 298 in 2020. Under alternative assumptions regarding physician lifestyle changes (such as hours worked) and increased productivity, the effective supply of physicians (FTEs) may grow to nearly 1.08 million physicians in 2020. The most probable aggregate projection suggests that the supply of physicians will number approximately 1.02 million FTEs in 2020.
  2. At the same time, for a number of reasons and under a number of scenarios and models, the demand for physicians is likely to grow even more rapidly over this period than the supply. It is likely that the demand for physician services will grow to between 1.03 million and 1.24 million physicians in 2020. The three major factors driving the increase in demand will be: a) the projected U.S. population growth of 50 million persons (18 percent) between 2000 and 2020; b) the aging of the population, as the number of Americans over 65 increases from 35 million in 2000 to 54 million in 2020; and c) the changing age-specific per capita physician utilization rates, with those under age 45 using fewer services and those over age 45 using more services.
  3. The need for services, reflecting primarily the use of services under universal insurance and increased utilization review processes, is also expected to increase over the period. Need is projected to grow to between 1.09 and 1.17 million physicians in 2020.
  4. If the Nation’s population continues to use services in the future as it has in the past, and if physicians practice in the future as they have in the past, then the Nation is likely to face a shortage of physicians in the coming years.
    1. When the midpoint of the projected range of future supply and demand is used, the Nation is projected to face a shortage of about 85,000 physicians in 2020.
    2. When the midpoint of the projected range of supply and need is used, the Nation is projected to face a shortage of about 96,000 physicians in 2020.
  5. The models and alternative scenarios used to make the predictions included a number of factors that could have a major impact on supply, demand, and need and, consequently, on a potential gap in the physician supply.
    1. Many of these factors are likely to add to the shortage of physicians. Some of these have been included in the report as scenarios that could have an impact on the supply or demand for physicians. These include the following:
      • Changing lifestyles for the newest generation of physicians, with the possibility that new physicians will work fewer hours than their predecessors;
      • Continuation of the rate of increase in the use of physician services by those over 45, which has been increasing for the past 20 years, and increased use of services by the baby-boom generation compared to prior generations; and
      • Expected increases in the Nation’s wealth that would contribute to continued increases in the use of medical services.
      Other factors could also lead to larger shortages and are not included in the baseline projections or alternative scenarios. These include the following:
      • A potential increase in non-patient care activities by physicians, including research and administrative activities;
      • A potential change in practice patterns for physicians over 50, including a reduction in hours worked before retirement and earlier retirement patterns;
      • Possible increases in departures from practice due to liability concerns of physicians;
      • Decreases in hours worked by physicians in training;
      • Possible decreases in immigration of graduates of foreign medical schools;
      • Possible increases in the number of physicians limiting the number of patients on their panel (sometimes referred to as “boutique medicine”);
      • Advances in genetic testing that could lead to increases in the use of services as individuals learn they are at risk for certain illnesses or conditions; and
      • Additional medical advances likely to keep individuals with chronic illnesses alive longer without curing their illnesses.
    2. A number of factors also may limit future shortages. These include factors for which estimates of their impact are presented in the report under different scenarios. These include the following:
      • Increases in productivity, such as through improved technologies and information systems; and
      • More effective utilization review and quality assurance efforts to weed out inappropriate or unnecessary services.
      Other factors not included in the supply, demand, and need projections with the potential to reduce projected shortages include the following:
      • Increases in the supply and use of nurse practitioners, physician assistants, and other non-physician clinicians;
      • Increases in costs and cost sharing; and
      • Medical breakthroughs that decrease service use.
  6. There are already a growing number of reports of, and concerns with, shortages in specific specialties. These include such specialties as radiology (Sunshine 2001), anesthesiology (Schubert et al 2001; Miller and Lanier 2001; Schubert et al 2003), cardiology (Foot et al 2000), rheumatology (Boyce 2003), nephrology (Neilson et al 2001), pulmonary disease/critical care (Angus et al 2000; Pronovost et al 2002), and child psychiatry (Kim et al 2001).
  7. Although the percentage of the Nation’s physicians who are generalists has increased slightly over the past decade, it is currently about 38 percent, well below the 50 percent target recommended in COGME’s Third Report. Even in the Kaiser Health Plans, only about 40 percent of their physicians in 2001 and 2002 (Weiner 2004) were generalists. Results of surveys of new physicians completing training in New York and California indicate that demand for generalists is less than demand for most non-generalists, further weakening the case for the 50 percent generalist goal (Nolan et al 2003a, 2003b).
RECOMMENDATIONS
Preamble
The State of the Nation’s health care workforce directly affects both the health of the American public and the economics of health care. It is not our intent to codify or explicitly endorse the current health care system. Given the constraints and confines of the available data, these recommendations are a feasible and realistic approach to physician workforce planning.
In light of the likely gap between the expected supply, demand, and need for physicians in the future, COGME recommends that the Nation undertake a multi-pronged strategy that includes: a modest increase in medical education and training capacity over the next decade; efforts to increase physician productivity; and increased tracking and assessments of the supply, demand, and need for physicians. In addition, because underserved communities are most likely to be affected by shortages, COGME recommends that the National Health Service Corps (NHSC) and other Federal programs designed to address geographic and specialty maldistribution and to increase diversity be expanded. Specific recommendations are presented below.
 
1. To meet the future physician workforce demand and need in the U.S., COGME recommends that:
  • The number of physicians entering residency training each year be increased from approximately 24,000 in 2002 to 27,000 in 2015; and
    • The distribution between generalists and non-generalists should reflect ongoing assessments of demand; therefore, COGME does not recommend a rigid national numerical target.
The analysis presented in this report indicates that the Nation is likely to be facing a shortage of physicians in the coming years, particularly in non-generalist specialties. To begin to address this likely shortage, COGME recommends that the total number of physicians entering residency training in the U.S. be increased to 27,000 per year over the next decade. This action would lead to an increase in the Nation’s physician workforce by about 3 percent (30,000 physicians) by 2020. Although this level of new entrants into medicine will be insufficient to meet future needs, it is an important step.
This physician workforce goal is presented as an absolute number rather than as a percentage of the number of U.S. medical graduates in a specific year. This absolute number is easier to understand and track, and therefore should be a more useful target for the Nation. When presented as a percentage of medical school graduates, the recommended number of entrants into residency training is equal to 158 percent of the number of 1993 U.S. medical graduates and 150 percent of the 2000 U.S. medical school graduates.
Currently, approximately 37 percent of new physicians are entering generalist specialties, and 63 percent are entering non-generalist specialties. COGME recommends below that the Nation undertake studies to track overall specialty-specific need, demand, and distribution and to share this information with the medical education and training community. Specialty-specific need and demand for physicians are likely to vary over time and by region. Therefore, a single national goal is inappropriate. Physicians should be encouraged to select specific specialties with shortages. This selection could be facilitated by providing physicians information on practice opportunities by specialties and, where appropriate, should be offered such fiscal incentives as loan repayment opportunities.
2. Increase total enrollment in U.S. medical schools by 15 percent from their 2002 levels over the next decade.
To assure reasonable access to care for Americans in coming years, COGME recommends that total U.S. allopathic and osteopathic medical school enrollment be increased by 15 percent by 2015. This step will require a combination of increased enrollment at existing medical schools and, potentially, the establishment of a number of new medical schools.
A modest increase in medical school enrollment over the next decade will have only a limited impact on the total supply of physicians in 2020 but would provide a base for responding to future needs. Decisions on medical school capacity need to be made now if the Nation is going to be able to produce more U.S. medical school graduates in 2015 and beyond.
Between 1982 and 2001, the number of medical students in the U.S. increased 7 percent while the U.S. population grew 23 percent, leading to a 13 percent net decrease in medical school students per capita in the U.S. Between 2000 and 2020, the U.S. population is projected to increase by 18 percent while medical school capacity is scheduled to increase by only about 4 percent, leading to a further decrease in per capita medical students. The recommended 15 percent increase would still leave the number of medical students per capita well below the 1980 level.
If the actual shortage is not as significant as predicted in this report, the modest increase of about 3,000 new U.S. graduates per year by 2015 would allow the U.S. to reduce its current reliance on the approximately 5,200 international medical school graduates (IMGs) who enter residency training each year. This policy would be consistent with those advocated by many observers (Mullan 2000). Most IMGs come from countries that have far fewer physicians per capita than the U.S. has.
Given the uncertainty inherent in long-term forecasting of supply, demand, and need, and the cost of a major expansion in medical school capacity, COGME does not recommend that the Nation attempt to address all the possible shortages through a dramatic increase in medical education capacity at the present time. Rather, COGME recommends that the medical education community increase enrollment moderately now and that the Nation take other steps that have the potential to reduce future shortages. Although it may be necessary to increase enrollment more than 15 percent in the coming years, the decision should be made based on further study over the next few years, as discussed in recommendation five below.
At this time, the Council is not recommending a new Federal program to encourage new medical schools or increased enrollment at existing medical schools. It is hoped that the medical education community and States will respond to the recommendations in this report and to the growing evidence of unmet physician workforce needs.
3. Phase in an increase in the number of residency and fellowship positions eligible for funding from Medicare to parallel the increase in U.S. medical school graduates recommended above.
Over the next decade, teaching hospitals will need to increase the number of training positions to accommodate the increasing number of U.S. medical school graduates. The current cap on the number of residents and fellows eligible for Medicare reimbursement strongly discourages teaching hospitals from increasing the number of residents. To encourage a modest increase in residents, COGME recommends that the cap be increased slowly over the next decade.
The current cap was intended to discourage increases in the number of physicians trained in the U.S. It was conceived and approved when there was a period of concern with potential surpluses of physicians and when it appeared that managed care would reduce the use of health care services. As the Nation now looks at its physician needs for 2015 and beyond, the far greater likelihood is a physician shortage. The Medicare policy should be adjusted to help meet future physician needs that will be driven in large part by the growing number of elderly covered by the Medicare program. In light of the growth in graduates of osteopathic schools over the past decade and the increasing number of entrants to allopathic schools, it is important to begin to increase the GME cap as soon as possible.
4. Develop systems to track the supply, demand, need, and distribution of physicians, and undertake a comprehensive re-assessment within the next 4 years to guide future decisions on medical education capacity.
Given the costs of increasing medical education and training capacity and the uncertainty inherent in any effort to forecast physician workforce many years into the future, it is strongly recommended that the Nation develop systems to track physician workforce supply, demand, need, and distribution on a regular and consistent basis. This recommendation is especially important in light of the many years needed to make changes in the supply of physicians.
In addition to ongoing tracking, COGME recommends that the Nation undertake a comprehensive re-assessment within the next 4 years that would consider the many factors that could have an impact on the physician workforce in the future in greater depth than the current re-assessment. Major industries, especially those in which changes in production require both substantial investments and many years to implement, exemplify this point. The leaders in these industries recognize the critical role of regular assessments of the current and future marketplace. The current study considers available data, but important gaps exist in these data as well as in our understanding of physician practice patterns. In addition, some information (e.g., retirement patterns of the baby-boom generation of physicians) cannot be known at this time.
5. Additional specialty-specific studies are needed to better understand the physician workforce needs and to inform the medical education community and policy makers of the Nation’s specialty-specific needs.
On the basis of available data, the Nation appears to have a ratio of 38 percent generalist specialties and 62 percent non-generalist specialties. This greater demand for non-generalist specialties is borne out by surveys of new physicians completing residency training in the U.S. and the growing number of reports of shortages in non-generalist specialties (Schubert et al 2003; Miller and Lanier 2001; Schubert et al 2001; Foot et al 2000; Kim et al 2001; Suneja et al 2001; Neilson et al 2001; Angus et al 2000; Pronovost et al 2002; Sunshine 2001; Organ 2002; Etzoni et al 2003; Fleming et al 2003).
Experience over the past decade has demonstrated that medical students, physicians in training, residency programs, and teaching hospitals respond to marketplace signals on supply and demand for different specialties. Unfortunately, specialty-specific studies have been conducted only sporadically in the past and often used questionable research methods and data. The Federal Government should take a leadership role in developing and encouraging common methodologies for specialty-specific studies.
Providing the medical education community and policy makers with better information on current and future needs and on gaps in physician supply by specialty should contribute to a specialty mix more consistent with national needs. Accurate and timely information and data are a prerequisite for an effective market of any type. This information should help guide Federal policies related to the physician workforce.
6. Promote efforts to increase the productivity of physicians.
The Nation should consider several steps to promote productivity improvements. These steps include:
  1. Funding to evaluate the effectiveness and efficiency of alternative models of care, and practice and organizational arrangements;
  2. Evaluation of specific new technologies;
  3. Dissemination of information to physicians on the effectiveness of alternative models of care, new technologies, and other strategies to improve productivity; and
  4. Introduction of reimbursement policies to support implementation of productivity enhancements.
A modest annual rate of increase in physician productivity would have a major long-term impact on the number of new physicians needed by the Nation. These steps could also encourage physicians to practice longer rather than retire or leave medical practice, thus effectively increasing the supply of physicians.
New technologies and improvements in existing technologies have the potential to increase productivity, improve quality, and increase physician satisfaction. Particularly promising is the potential for the electronic medical record and other advances in information technology. These advances have the potential to increase efficiency and effectiveness, to reduce the time needed for documentation, and to speed the retrieval of needed information. Remote patient monitoring systems, telecommunications advances, and Internet access to the latest medical knowledge and technologies have the potential to increase the number of patients who can be cared for by a physician.
There are a number of barriers to the expansion of effective new technologies. First, many of these technologies require an enormous investment to develop and acquire. Second, many new technologies are still to be perfected and are evolving rapidly, leading to appropriate caution on the part of physicians and the organizations that use them. A third barrier for certain types of technologies is reimbursement policies. For example, if insurers do not cover group sessions or interactions between physician and patient over the Internet, then these approaches will be less attractive to physicians and patients.
7. Expand programs and develop policies that:
  • Address geographic maldistribution of physicians,
  • Improve access to care for underserved populations and communities,
  • Promote appropriate specialty distribution and deployment,
  • Promote workforce diversity, and
  • Support analyses of data related to these issues.
The projected shortage of physicians is likely to have the greatest impact on underserved and poorer communities that have historically had the greatest difficulty recruiting and retaining physicians. To assure access for our most needy citizens, it will be important to maintain and expand programs that support access to physician services by underserved populations. In anticipation of future shortages, the number of scholarship and loan repayment awards under the NHSC should be increased.
As indicated in this report, shortages for non-generalists are likely. Although generalists play a central role in underserved communities, these communities also require access to non-generalists. Therefore, COGME recommends that the NHSC be expanded to include non-generalist specialties. These awards should be targeted to specialties with documented shortages in underserved communities. Giving underserved communities access to non-generalists should be accomplished while maintaining an emphasis on access to primary care services. By identifying specialties experiencing shortages for purposes of the NHSC program, the Federal Government would also send an important message to medical students about specialties in need.
Title VII of the Public Health Service Act includes programs specifically designed to encourage practice in rural and other underserved areas, to increase the diversity of the workforce, to promote more effective medical and interdisciplinary education, and to collect and analyze workforce data. These programs play a critical role in helping assure access to needed services and will be particularly important in a period of physician shortage. COGME recommends that these programs receive continued support.
In addition to physician workforce programs that directly address needs in health care delivery, policy exerts its influence through reimbursement and regulatory actions. For example, direct and indirect GME payments through Medicare, as well as differential payments for health care services, have an influence on training opportunities, medical specialty choices, and career location decisions. These influences should be evaluated, understood, and more closely aligned with health care policy goals.
For further reading, please see: http://www.cogme.gov/report16.htm#sumrec

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