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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.