TRENDS IN PHYSICIAN SUPPLY AND DEMAND TRENDS IN PHYSICIAN SUPPLY AND DEMAND Richard A. Cooper, M.D Richard A. Cooper, M.D . . Florida Board of Governors Orlando March 17, 2004
Jan 22, 2016
TRENDS IN PHYSICIAN SUPPLY AND DEMANDTRENDS IN PHYSICIAN SUPPLY AND DEMAND
Richard A. Cooper, M.DRichard A. Cooper, M.D..
Florida Board of GovernorsOrlando
March 17, 2004
TRENDS IN HEALTH EXPENDITURES TRENDS IN HEALTH EXPENDITURES
and theand the
DEMAND FOR ADVANCED CLINICAL SERVICESDEMAND FOR ADVANCED CLINICAL SERVICES
MACRO-FORECASTING USINGMACRO-FORECASTING USING THE TREND MODELTHE TREND MODEL
Economy Economy RelativeRelative
PopulationPopulation DemandDemand
Trends Trends ~~ FUTUREFUTURE ProductivityProductivity RelativeRelative
SubstitutionSubstitution SupplySupply
Sufficiency *
DEMANDDEMAND
SUPPLYSUPPLY
x
ECONOMIC GROWTHECONOMIC GROWTH ~ 1~ 1.0%.0%
MEDICAL CAREMEDICAL CARESPENDINGSPENDING
~ ~ 1.5%1.5%
PHYSICIANPHYSICIANSUPPLYSUPPLY ~ ~ 0.75%0.75%
HEALTH CAREHEALTH CARELABOR FORCELABOR FORCE
~ ~ 1.2%1.2%
4-5 year lag
10 year lag
ECONOMIC GROWTHECONOMIC GROWTH
SUCCESSSUCCESS
HEALTH CAREHEALTH CAREEMPLOYMENTEMPLOYMENT
TECHNOLOGYTECHNOLOGY
WORKERWORKERPRODUCTIVITYPRODUCTIVITY
POLITICSPOLITICS
HEALTH CAREERSHEALTH CAREERSEDUCATIONEDUCATION
““COMPLEX ADAPTIVE SYSTEMCOMPLEX ADAPTIVE SYSTEM””
PHYSICIANPHYSICIANSUPPLYSUPPLY
ETHNICITYETHNICITY
AGINGAGING
SOCIAL POLICYSOCIAL POLICY
MEDICAL CAREMEDICAL CARESPENDINGSPENDING
RESEARCHRESEARCHNIH NIH $27B $27B
EMPLOYERSEMPLOYERS
PROMISEPROMISEof SUCCESSof SUCCESS
DESIRES andDESIRES andEXPECTATIONSEXPECTATIONS
VENTURE CAPITALVENTURE CAPITAL
ECONOMIC DETERMINANTS OF HEALTH CARE SPENDINGECONOMIC DETERMINANTS OF HEALTH CARE SPENDING
AND THE DEMAND FOR PHYSICIANSAND THE DEMAND FOR PHYSICIANS
InfiniteInfinitePossibilitiesPossibilities
InfiniteInfiniteDesireDesire
Financial Financial ResourcesResources
GG DD PP
ECONOMIC DETERMINANTS OF HEALTH CARE SPENDINGECONOMIC DETERMINANTS OF HEALTH CARE SPENDING
AND THE DEMAND FOR PHYSICIANSAND THE DEMAND FOR PHYSICIANS
InfiniteInfinitePossibilitiesPossibilities
InfiniteInfiniteDesireDesire
SocialSocialEquityEquity
GG DD PP
ECONOMIC CORRELATES RELATING TOECONOMIC CORRELATES RELATING TO
THE DEMAND FOR PHYSICIANSTHE DEMAND FOR PHYSICIANS
RELATIONSHIP BETWEEN PHYSICIAN SUPPLY RELATIONSHIP BETWEEN PHYSICIAN SUPPLY and GROSS DOMESTIC PRODUCT and GROSS DOMESTIC PRODUCT
1929-2000 1929-2000
100
150
200
250
300
$0 $10,000 $20,000 $30,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
1929
1970
1990
1945-60
2000
1980
Insufficient supply leading to
medical school expansion
in the 1970s.
= = 1.5%/capita/yr1.5%/capita/yr
1996
R2 = 0.5273
50
100
150
200
250
300
350
400
$10,000 $20,000 $30,000 $40,000State Per Capita Income (1996 $)
Phy
sici
ans
per
100,
000
. o
f P
opul
atio
n
States
Florida
STATE PER CAPITA INCOME vs. STATE PER CAPITA INCOME vs. STATE PHYSICIAN SUPPLYSTATE PHYSICIAN SUPPLY
19961996
1996
R2 = 0.5273
1970
R2 = 0.5129
50
100
150
200
250
300
350
400
$10,000 $20,000 $30,000 $40,000
State Per Capita Income (1996 $)
Phy
sici
ans
per
100,
000
.
of
Pop
ulat
ion
1996
1970
STATE PER CAPITA INCOME vs. STATE PER CAPITA INCOME vs. STATE PHYSICIAN SUPPLYSTATE PHYSICIAN SUPPLY
1970 and 19961970 and 1996
1970 data from Reinhardt, 1975
0
20
40
60
80
100
$15,000 $20,000 $25,000 $30,000 $35,000
Personal Income Per Capita
Phy
sici
ans
Per
100
,000
.
of P
opul
atio
nPHYSICIAN SPECIALTIES vs.PHYSICIAN SPECIALTIES vs.STATE PER CAPITA INCOMESTATE PER CAPITA INCOME
19951995
Medical SpecialistsMedical Specialists
Surgical SpecialistsSurgical Specialists
Family/GeneralFamily/General
PracticePractice
PER CAPITA INCOME vs PHYSICIAN SUPPLY PER CAPITA INCOME vs PHYSICIAN SUPPLY in Metropolitan Statistical Areas (MSAs)in Metropolitan Statistical Areas (MSAs)
Per Capita Income
Physicians per 100,000of Population
Active Physicians
Medical Specialists
Surgical Specialists
Family Practice
Residents includedResidents included
PER CAPITA INCOME vs PHYSICIAN SUPPLY PER CAPITA INCOME vs PHYSICIAN SUPPLY in Metropolitan Statistical Areas (MSAs)in Metropolitan Statistical Areas (MSAs)
Per Capita Income
Physicians per 100,000of Population
Active Physicians
Medical Specialists
Surgical Specialists
Family Practice
Residents includedResidents included
Miami
West Palm
TREND MODEL PROJECTIONSTREND MODEL PROJECTIONS
PHYSICIAN DEMAND TRENDPHYSICIAN DEMAND TRENDvs. GROSS DOMESTIC PRODUCT vs. GROSS DOMESTIC PRODUCT
1929-2000 and Projected to 20201929-2000 and Projected to 2020
100
150
200
250
300
350
400
$0 $10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
19291929
19751975
20002000
Approx 2020Approx 2020
GDP GDP 2.0% 2.0% per capita per yearper capita per year
GDP GDP 1.0% 1.0%
Health spending Health spending ~1.5% ~1.5%
Health workforce Health workforce ~1.2% ~1.2%
Physician workforce Physician workforce ~ 0.75% ~ 0.75%
100
150
200
250
300
350
400
$0 $10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
19291929
20002000Projected SupplyProjected Supply
ApproximatelyApproximately 2020 2020
PHYSICIAN DEMAND and SUPPLY PHYSICIAN DEMAND and SUPPLY vs. GROSS DOMESTIC PRODUCT vs. GROSS DOMESTIC PRODUCT 1929-2000 and Projected to ~20201929-2000 and Projected to ~2020
19801980
PHYSICIAN DEMAND and EFFECTIVE SUPPLY PHYSICIAN DEMAND and EFFECTIVE SUPPLY 1929-2000 and Projected to ~2020 1929-2000 and Projected to ~2020
100
150
200
250
300
350
400
$0 $10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
19291929
20002000Projected SupplyProjected Supply
Effective SupplyEffective SupplyPhysician agePhysician age
Female physiciansFemale physicians--------------------------------------------------------
Lifestyle, EmploymentLifestyle, EmploymentNonclinical careers Nonclinical careers
Early retirementEarly retirementResident hoursResident hours
ApproximatelyApproximately 2020 2020
PHYSICIANS, NONPHYSICIAN CLINICIANS and OTHER HEALTH WORKERS
1850-2010
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
1850 1880 1910 1940 1970 2000
Hea
lth E
mpl
oym
ent
per 1
00,0
00 o
f Pop
ulat
ion
.
Managers
Technicians
Therapists
Aides
LPNs
RNs
Pharmacists
Dentists
NPCs
Physicians
Adapted from Kendix and Getzen and the Bureau of Labor Statistics
2010
Optometrists ------------------------------
Nurse Anesthetists-------------------------------
Podiatrists
SpecialtyNPs & PAs
Chiropractors
Primary Care
Nurse Practitioners-----------------------------------
Nurse-Midwives-----------------------------------
Physician Assistants
PHYSICIANS
ClinicalNurse
Specialists
NaturopathsPsychologists
Clin. Social Workers
Psychiatric Nurses
Counselors
Therapists
Acupuncturists
Pharmacists
OVERLAPPING RESPONSIBILITIES OFOVERLAPPING RESPONSIBILITIES OFPHYSICIANS AND NONPHYSICIAN CLINICIANSPHYSICIANS AND NONPHYSICIAN CLINICIANS
COMPLEX CARECOMPLEX CARE
MULTISYSTEM DISEASE CAREMULTISYSTEM DISEASE CARE
CHRONIC DISEASE MANAGEMENTCHRONIC DISEASE MANAGEMENT
MINOR and SELF-LIMITED DISORDERSMINOR and SELF-LIMITED DISORDERS
SYMPTOM CONTROLSYMPTOM CONTROL
WELLNESS CARE and PREVENTIONWELLNESS CARE and PREVENTION
COUNSELING and EDUCATIONCOUNSELING and EDUCATION
NONPHYSICIAN NONPHYSICIAN CLINICIANSCLINICIANS
PHYSICIANSPHYSICIANS
100
150
200
250
300
350
400
$0 $10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
19291929
20002000
Added Added NonphysicianNonphysiciancliniciansclinicians
ApproximatelyApproximately 2020 2020
NonphysicianNonphysiciancliniciansclinicians
--------------------------------------------------------
NPs, PAs, MidwivesNPs, PAs, MidwivesPsychologists, Clinical Soc. WorkersPsychologists, Clinical Soc. Workers
Chiropractors, AcupuncturistsChiropractors, AcupuncturistsOptometrists, PodiatristsOptometrists, Podiatrists
Nurse AnesthetistsNurse Anesthetists
PHYSICIAN DEMAND and PHYSICIAN DEMAND and SUPPLY of PHYSICIANS and NPCsSUPPLY of PHYSICIANS and NPCs1929-2000 and Projected to ~2020 1929-2000 and Projected to ~2020
TREND PROJECTIONSTREND PROJECTIONS
OF THE DEMAND FOR PHYSICIANSOF THE DEMAND FOR PHYSICIANS
BUREAU OF LABOR STATISTICSBUREAU OF LABOR STATISTICS HEALTH SERVICES EMPLOYMENT HEALTH SERVICES EMPLOYMENT
2000-20152000-2015
12,000
14,000
16,000
18,000
2000 2005 2010 2015
Year
Em
ploy
men
t x1
,000
.
Trend ModelTrend Model Health Care Employment Health Care Employment
Bureau of Labor StatisticsBureau of Labor StatisticsHealth Care EmploymentHealth Care Employment
1
1.1
1.2
1.3
1.4
1.5
2000 2005 2010 2015 2020
Year
Dem
and
for
Phy
sici
ans
and
Nur
ses,
.
% o
f 200
0
HEALTH RESOURCES AND SERVICES ADMINISTRATIONHEALTH RESOURCES AND SERVICES ADMINISTRATIONDEMAND FOR NURSES DEMAND FOR NURSES
2000-20202000-2020
HRSA HRSA NursesNurses
Trend Model Trend Model PhysiciansPhysicians
100%
110%
120%
130%
140%
150%
160%
2000 2005 2010 2015
Year
Per C
apita
Exp
enditu
res
.
% o
f 2000
.HEALTH CARE FINANCING ADMINISTRATIONHEALTH CARE FINANCING ADMINISTRATION HEALTH CARE EXPENDITURES PER CAPITAHEALTH CARE EXPENDITURES PER CAPITA
2000-20132000-2013
““The lagged impact of an The lagged impact of an improving economic environment improving economic environment
(with an average lag of about (with an average lag of about three years) was the primary three years) was the primary
driver in the steady increase in driver in the steady increase in the use and intensity of personal the use and intensity of personal health care from 1999 to 2002.” health care from 1999 to 2002.”
((CMS, 2004CMS, 2004))
1996 $, percent 1996 $, percent of 2000of 2000
HCFAHCFAExpendituresExpenditures
Trend Model Trend Model ExpendituresExpenditures
VARIOUS PHYSICIAN TREND PROJECTIONSVARIOUS PHYSICIAN TREND PROJECTIONS
400,000
600,000
800,000
1,000,000
1,200,000
1980 1990 2000 2010 2020
Phys
icia
ns
.
Physician Supply
Supply projections
Salsberg (COGME) 2003
Lewin (BHPr) 2003
BLS 1982-2000
Schwartz 1988
Cooper 1994
Cooper 2002
Demand Demand TrendTrend
SupplySupply
PLANNING PARAGIGMSPLANNING PARAGIGMS
Appropriate Tasks Appropriate Tasks Visits x Visits x Time per VisitTime per Visit = FTEs Needed = FTEs Needed
Time per Doc Time per Doc
TASK AND TIME MODELSTASK AND TIME MODELS
Adjusted needs model (GMENAC)Adjusted needs model (GMENAC)= >750 diseases= >750 diseases
Demand-utilization model (BHPr)Demand-utilization model (BHPr)Demographic (age/race/gender = 36) x Insurance (3) x Demographic (age/race/gender = 36) x Insurance (3) x
Specialties (18) x NCHS Datasets (5)Specialties (18) x NCHS Datasets (5)=9,720 cells=9,720 cells
Managed care model (Weiner)Managed care model (Weiner)Count all the HMO docsCount all the HMO docs
? Missed docs, different patient characteristics ? ? Missed docs, different patient characteristics ? 40 hour doc =1.0 FTEs.40 hour doc =1.0 FTEs.
PHYSICIAN SUPPLY and DEMANDPHYSICIAN SUPPLY and DEMAND
400,000
600,000
800,000
1,000,000
1,200,000
1980 1990 2000 2010 2020
Phys
icia
ns
.
Physician Supply
Supply projections
Salsberg (COGME) 2003
BLS 1982-2000
Schwartz 1988
Cooper 1995
Cooper 2002
GMENAC 1980 (1990, 2000)
COGME 1994 (2000)
Weiner 1994 (2000, 2020)
BHPr 1995 (2000)
BHPr 1996 (2000)
Task and Time Task and Time ModelsModels
SupplySupply
Demand Demand TrendTrend
THE SHAPE OF PHYSICIAN SUPPLYTHE SHAPE OF PHYSICIAN SUPPLY
NOW AND INTO THE FUTURENOW AND INTO THE FUTURE
100
150
200
250
300
350
400
$0 $10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
SupplySupply
Demand
Demand
DEFICIT WITH NO ADDITIONAL USMGs or IMGsDEFICIT WITH NO ADDITIONAL USMGs or IMGs
DeficiencyDeficiency~200,000~200,000physiciansphysicians
(~20%)(~20%)
~2020-2025~2020-2025
You are HereYou are Here
Waiting times for patientsWaiting times for patients
Salaries, bonuses for new physiciansSalaries, bonuses for new physicians
Refusal by physicians to accept Medicare patients Refusal by physicians to accept Medicare patients
Boutique (VIP) practicesBoutique (VIP) practices
Recruiters and surveysRecruiters and surveys
Resident exit surveysResident exit surveys
Federal forecastersFederal forecastersBureau of Labor StatisticsBureau of Labor StatisticsHealth Care Financing Adm. (CMS)Health Care Financing Adm. (CMS)
State medical associationsState medical associationsCalifornia, Massachusetts, Arizona, New California, Massachusetts, Arizona, New Mexico, Oregon, TexasMexico, Oregon, Texas
Medical school deansMedical school deans
INDICATIONS OF CURRENT AND IMPENDING INDICATIONS OF CURRENT AND IMPENDING PHYSICIAN SHORTAGESPHYSICIAN SHORTAGES
AnesthesiologyAnesthesiologyRadiology Radiology CardiologyCardiologyGastroenterologyGastroenterologyOrthopedicsOrthopedicsDermatologyDermatologyOncology Oncology UrologyUrologyPulmonary/Critical CarePulmonary/Critical Care
Emergency medicineEmergency medicineGeneral surgeryGeneral surgeryNeurosurgeryNeurosurgeryNeurologyNeurologyOb/GynOb/GynPediatric sub-specialtiesPediatric sub-specialtiesPsychiatry Psychiatry
… …and early signs of shortages and early signs of shortages in primary carein primary care
GREATEST CURRENT PHYSICIAN SHORTAGESGREATEST CURRENT PHYSICIAN SHORTAGES
20% of 20% of physiciansphysicians
THE IMPERATIVETHE IMPERATIVE
The conditions that have led to the current physician shortages The conditions that have led to the current physician shortages have been evolving for more than a decade.have been evolving for more than a decade.
To continue to do nothing invites public discontent To continue to do nothing invites public discontent and forces the profession of medicine to redefine itself and forces the profession of medicine to redefine itself
in ever more narrow scientific and technological spheres.in ever more narrow scientific and technological spheres.
Yet, the solutions are neither simple nor immediate.Yet, the solutions are neither simple nor immediate.
These circumstances demand consensus building These circumstances demand consensus building and thoughtful planning. and thoughtful planning.
Thank you.