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TRENDS IN PHYSICIAN SUPPLY AND DEMAND
Richard A. Cooper, M.D.
Florida Board of Governors
Orlando
March 17, 2004
TRENDS IN HEALTH EXPENDITURES
and the
DEMAND FOR ADVANCED CLINICAL SERVICES
MACRO-FORECASTING USING
THE TREND MODEL
DEMAND
Sufficiency *
x
SUPPLY
 Economy
 Population
Trends
 Productivity
 Substitution
 Relative
Demand
~
FUTURE
 Relative
Supply
ECONOMIC GROWTH
 ~ 1.0%
4-5 year lag
MEDICAL CARE
SPENDING
 ~ 1.5%
HEALTH CARE
LABOR FORCE
 ~ 1.2%
10 year lag
PHYSICIAN
SUPPLY
 ~ 0.75%
“COMPLEX ADAPTIVE SYSTEM”
ECONOMIC GROWTH
POLITICS
SOCIAL POLICY
DESIRES and
EXPECTATIONS
AGING
EMPLOYERS
SUCCESS
WORKER
PRODUCTIVITY
MEDICAL CARE
SPENDING
ETHNICITY
PROMISE
of SUCCESS
RESEARCH
NIH  $27B
HEALTH CARE
EMPLOYMENT
HEALTH CAREERS
EDUCATION
VENTURE CAPITAL
PHYSICIAN
SUPPLY
TECHNOLOGY
ECONOMIC DETERMINANTS OF HEALTH CARE SPENDING
AND THE DEMAND FOR PHYSICIANS
Infinite
Desire
Financial
Resources
Infinite
Possibilities
G
D
P
ECONOMIC DETERMINANTS OF HEALTH CARE SPENDING
AND THE DEMAND FOR PHYSICIANS
Infinite
Desire

Social
Equity

Infinite
Possibilities
G
D
P
ECONOMIC CORRELATES RELATING TO
THE DEMAND FOR PHYSICIANS
Active Physicians per 100,000 .
of Population
300
RELATIONSHIP BETWEEN PHYSICIAN SUPPLY
and GROSS DOMESTIC PRODUCT
1929-2000
2000
250
1990
1980 
200
1970 
150
1945-60
1929
Insufficient supply
leading to
medical school
expansion
in the 1970s.
100
$0
$10,000
$20,000
$30,000
GDP per Capita (1996 dollars)
=
1.5%/capita/yr
STATE PER CAPITA INCOME vs.
STATE PHYSICIAN SUPPLY
1996
Physicians per 100,000 .
of Population
400
350
1996
2
300
R = 0.5273
250
States
200
Florida
150
100
50
$10,000
$20,000
$30,000
State Per Capita Income (1996 $)
$40,000
350
of Population
Physicians per 100,000 .
400
STATE PER CAPITA INCOME vs.
STATE PHYSICIAN SUPPLY
1970 and 1996
1996
2
300
R = 0.5273
250
1996
200
1970
1970
150
2
R = 0.5129
100
50
$10,000
$20,000
$30,000
$40,000
State Per Capita Income (1996 $)
1970 data from Reinhardt, 1975
Physicians Per 100,000 .
of Population
100
PHYSICIAN SPECIALTIES vs.
STATE PER CAPITA INCOME
1995
Medical Specialists
80
60
Surgical Specialists
40
Family/General
Practice
20
0
$15,000
$20,000
$25,000
$30,000
$35,000
Personal Income Per Capita
PER CAPITA INCOME vs PHYSICIAN SUPPLY
in Metropolitan Statistical Areas (MSAs)
Active
Physicians
Physicians
per 100,000
of Population
Medical Specialists
Surgical Specialists
Family Practice
Residents included
Per Capita Income
PER CAPITA INCOME vs PHYSICIAN SUPPLY
in Metropolitan Statistical Areas (MSAs)
Miami
Physicians
per 100,000
of Population
Active
Physicians
West
Palm
Medical Specialists
Surgical Specialists
Family Practice
Residents included
Per Capita Income
TREND MODEL PROJECTIONS
PHYSICIAN DEMAND TREND
vs. GROSS DOMESTIC PRODUCT
1929-2000 and Projected to 2020
Active Physicians per 100,000 .
of Population
400
Approx 2020

350
GDP  2.0% per capita per year
300
2000
250
200
1975 
GDP  1.0%

Health spending  ~1.5%

Health workforce  ~1.2%

Physician workforce  ~ 0.75%
150
1929
100
$0
$10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
PHYSICIAN DEMAND and SUPPLY
vs. GROSS DOMESTIC PRODUCT
1929-2000 and Projected to ~2020
Active Physicians per 100,000 .
of Population
400
Approximately 2020

350
300
2000
Projected Supply
250
1980 
200
150
1929
100
$0
$10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
PHYSICIAN DEMAND and EFFECTIVE SUPPLY
1929-2000 and Projected to ~2020
Active Physicians per 100,000 .
of Population
400
Approximately 2020

350
300
Projected Supply
2000
250
Effective Supply
Physician age
Female physicians
200
--------------------------------------------------------
150
1929
Lifestyle, Employment
Nonclinical careers
Early retirement
Resident hours
100
$0
$10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
PHYSICIANS, NONPHYSICIAN CLINICIANS
and OTHER HEALTH WORKERS
1850-2010
Health Employment
per 100,000 of Population
.
4,000
3,500
Managers
3,000
Technicians
Therapists
2,500
Aides
2,000
LPNs
RNs
1,500
Pharmacists
1,000
Dentists
NPCs
500
Physicians
0
1850
1880
1910
1940
1970
2000
2010
Adapted from Kendix and Getzen and the Bureau of Labor Statistics
Specialty
Optometrists
NPs & PAs
Clinical
Nurse
Specialists
------------------------------
Nurse Anesthetists
-------------------------------
Podiatrists
PHYSICIANS
Psychologists
Clin. Social Workers
Psychiatric Nurses
Counselors
Therapists
Pharmacists
Acupuncturists
Primary Care
Naturopaths
Nurse Practitioners
-----------------------------------
Nurse-Midwives
-----------------------------------
Physician
Assistants
Chiropractors
OVERLAPPING RESPONSIBILITIES OF
PHYSICIANS AND NONPHYSICIAN CLINICIANS
PHYSICIANS
COMPLEX CARE
MULTISYSTEM DISEASE CARE
CHRONIC DISEASE MANAGEMENT
MINOR and SELF-LIMITED DISORDERS
SYMPTOM CONTROL
WELLNESS CARE and PREVENTION
COUNSELING and EDUCATION
NONPHYSICIAN
CLINICIANS
PHYSICIAN DEMAND and
SUPPLY of PHYSICIANS and NPCs
1929-2000 and Projected to ~2020
Active Physicians per 100,000 .
of Population
400
Approximately 2020

350
300
Added
Nonphysician
clinicians
2000
250
Nonphysician
clinicians
200
--------------------------------------------------------
150
1929
NPs, PAs, Midwives
Psychologists, Clinical Soc. Workers
Chiropractors, Acupuncturists
Optometrists, Podiatrists
Nurse Anesthetists
100
$0
$10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
TREND PROJECTIONS
OF THE DEMAND FOR PHYSICIANS
BUREAU OF LABOR STATISTICS
HEALTH SERVICES EMPLOYMENT
2000-2015
Employment x1,000 .
18,000
Bureau of Labor Statistics
Health Care Employment
16,000
Trend Model
Health Care Employment
14,000
12,000
2000
2005
2010
Year
2015
.
Demand for Physicians and Nurses,
% of 2000
HEALTH RESOURCES AND SERVICES ADMINISTRATION
DEMAND FOR NURSES
2000-2020
1.5
Trend Model
Physicians

1.4

1.3
HRSA
Nurses
1.2
1.1
1
2000
2005
2010
Year
2015
2020
HEALTH CARE FINANCING ADMINISTRATION
HEALTH CARE EXPENDITURES PER CAPITA
2000-2013
Per Capita Expenditures .
% of 2000 .
160%
150%
HCFA
Expenditures
140%
“The lagged impact of an
improving economic environment
(with an average lag of about
three years) was the primary
driver in the steady increase in
the use and intensity of personal
health care from 1999 to 2002.”
(CMS, 2004)
130%
120%
110%
Trend Model
Expenditures
100%
2000
2005
2010
Year
2015
1996 $, percent
of 2000
VARIOUS PHYSICIAN TREND PROJECTIONS
1,200,000
Physician Supply
Demand
Trend
Supply projections
1,000,000
Physicians .
Salsberg (COGME) 2003
Supply
Lewin (BHPr) 2003
800,000
BLS 1982-2000
Schwartz 1988
Cooper 1994
600,000
Cooper 2002
400,000
1980
1990
2000
2010
2020
PLANNING PARAGIGMS
TASK AND TIME MODELS
Appropriate Tasks  Visits x Time per Visit = FTEs Needed
Time per Doc
Adjusted needs model (GMENAC)
= >750 diseases
Demand-utilization model (BHPr)
Demographic (age/race/gender = 36) x Insurance (3) x
Specialties (18) x NCHS Datasets (5)
=9,720 cells
Managed care model (Weiner)
Count all the HMO docs
? Missed docs, different patient characteristics ?
40 hour doc =1.0 FTEs.
PHYSICIAN SUPPLY and DEMAND
1,200,000
Physician Supply
Demand
Trend
Supply projections
Salsberg (COGME) 2003
1,000,000
Physicians .
BLS 1982-2000
Schwartz 1988
Supply
Cooper 1995
800,000
Cooper 2002
GMENAC 1980 (1990, 2000)
COGME 1994 (2000)
Weiner 1994 (2000, 2020)
Task and Time
Models
600,000
BHPr 1995 (2000)
BHPr 1996 (2000)
400,000
1980
1990
2000
2010
2020
THE SHAPE OF PHYSICIAN SUPPLY
NOW AND INTO THE FUTURE
DEFICIT WITH NO ADDITIONAL USMGs or IMGs
Active Physicians per 100,000 .
of Population
400
~2020-2025
350
Deficiency
~200,000
physicians
(~20%)
300
250
You are Here
200
150
100
$0
$10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
INDICATIONS OF CURRENT AND IMPENDING
PHYSICIAN SHORTAGES
Waiting times for patients
Salaries, bonuses for new physicians
Refusal by physicians to accept Medicare patients
Boutique (VIP) practices
Recruiters and surveys
Resident exit surveys
Federal forecasters
Bureau of Labor Statistics
Health Care Financing Adm. (CMS)
State medical associations
California, Massachusetts, Arizona, New
Mexico, Oregon, Texas
Medical school deans
GREATEST CURRENT PHYSICIAN SHORTAGES
Anesthesiology
Radiology
Cardiology
Gastroenterology
Orthopedics
Dermatology
Oncology
Urology
Pulmonary/Critical Care
20% of
physicians
Emergency medicine
General surgery
Neurosurgery
Neurology
Ob/Gyn
Pediatric sub-specialties
Psychiatry
…and early signs of shortages
in primary care
THE IMPERATIVE
The conditions that have led to the current physician shortages
have been evolving for more than a decade.
To continue to do nothing invites public discontent
and forces the profession of medicine to redefine itself
in ever more narrow scientific and technological spheres.
Yet, the solutions are neither simple nor immediate.
These circumstances demand consensus building
and thoughtful planning.
Thank you.