Physician Supply and Demand [1 ed.] 9781614705840, 9781608761302

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Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Physician Supply and Demand, Nova Science Publishers, Incorporated, 2010. ProQuest Ebook Central,

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Physician Supply and Demand, Nova Science Publishers, Incorporated, 2010. ProQuest Ebook Central,

HEALTH CARE ISSUES, COSTS AND ACCESS

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

PHYSICIAN SUPPLY AND DEMAND

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

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HEALTH CARE ISSUES, COSTS AND ACCESS The Health Care Financial Crisis: Strategies for Overcoming an “Unholy Trinity" Cal Clark and Rene McEldowney (Editors) 2001. ISBN: 1-56072-924-4 Health Care Crisis in America James B. Prince (Editor) 2006. ISBN: 1-59454-698-4 A New Epidemic: Harm in Health Care-How to Make Rational Decisions about Medical and Surgical Treatment Aage R. Moller 2007. ISBN: 1-60021-884-9

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Decision Making in Medicine and Health Care Partricia C. Tolana (Editor) 2008. ISBN: 1-60021-870-9 Decision Making in Medicine and Health Care Partricia C. Tolana (Editor) 2008. ISBN: 978-1-60692-561-4 (E-book) Social Sciences in Health Care and Medicine Janet B. Garner and Thelma C. Christiansen (Editors) 2008. ISBN: 978-1-60456-286-6 Health Care Policies Linda A. Bartlette and Ida F. Lawson (Editors) 2008. ISBN: 978-1-60456-352-8 Handbook of Stress and Burnout in Health Care Jonathon R.B. Halbesleben (Editor) 2008. ISBN: 978-1-60456-500-3 Health Care Costs: Outlook and Options RAYMOND W. INHURST (EDITOR) 2009. ISBN: 978-1-60692-151-7

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Medicare Payment Policies to Physicians Katherine V. Bergen (Editor) 2009. ISBN: 978-1-60692-131-4 Comparative Effectiveness of Medical Treatments Peter Villa and Sophia Brun 2009 ISBN: 978-1-60741-109-3 Health Care Costs: Causes, Effects and Control Bernice R. Hofmann (EDITOR) 2009. ISBN: 978-1-60456-976-6 A Guide to Public Health Research Needs Raymond I. Turner 2009. ISBN: 978-1-60692-852-3

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A Guide to Public Health Research Needs Raymond I. Turner 2009. ISBN: 978-1-60876-605-5 (E-book) Handbook of Dental Care: Diagnostic, Preventative and Restorative Services Jose C. Taggart (EDITOR) 2009. ISBN: 978-1-60741-281-6 Handbook of Dental Care: Diagnostic, Preventative and Restorative Services Jose C. Taggart (EDITOR) 2009. ISBN: 978-1-61668-982-7 (E-book) Generic Drugs: Needs and Issues Ryan S. Blanton (EDITOR) 2009. ISBN: 978-1-60692-843-1 Medicare: A Primer Alice R. Williamson (Editor) 2009. ISBN: 978-1-60741-108-6

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A Health Insurance Model for Analyzing Legislative Policy Options Alan S. Burley (Editor) 2010. ISBN: 978-1-60741-052-2 Improving the Value of Health Care Shaun C. Turner and Erik S. Nguyen (Editors) 2010. ISBN: 978-1-60741-331-8 Technological Change and the Growth of Health Care Spending Andreas P. Gambrell (Editor) 2010. ISBN: 978-1-60741-112-3 Health Insurance: A Primer Leon V. Koch (Editor) 2010. ISBN: 978-1-61728-024-5

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Health Insurance: A Primer Leon V. Koch (Editor) 2010. ISBN: 978-1-61728-028-3 (E-book) Major Health Insurance Issues and Proposals Elizabeth I. Swanne (Editor) 2010. ISBN: 978-1-60741-330-1 Major Health Insurance Issues and Proposals Elizabeth I. Swanne (Editor) 2010. ISBN: 978-1-61728-098-6 (E-book) Reforming America’s Health Care System Damien B. Verbruggen (Editor) 2010. ISBN: 978-1-60741-532-9 Sociology of Interprofessional Health Care Practice: Critical Reflections and Concrete Solutions Simon Kitto, Janice Chesters, Jill Thistlethwaite and Scott Reeves (Editors) 2010. ISBN: 978-1-60876-866-0

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Physician Supply and Demand Adam Berényi (Editor) 2010. ISBN: 978-1-60876-130-2 Medicaid and Treatment for People with Substance Abuse Problems Bentson H. McFarland, Dennis McCarty, and Anne E. Kovas (Editors) 2010. ISBN: 978-1-61668-756-4 Transfusion – Think About It Trevor J. Cobain (Editor) 2010. ISBN: 978-1-61668-969-8

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Transfusion – Think About It Trevor J. Cobain (Editor) 2010. ISBN: 978-1-61728-455-7 (E-book)

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Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Physician Supply and Demand, Nova Science Publishers, Incorporated, 2010. ProQuest Ebook Central,

HEALTH CARE ISSUES, COSTS AND ACCESS

PHYSICIAN SUPPLY AND DEMAND

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

ADAM BERÉNYI EDITOR

Nova Science Publishers, Inc. New York

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Copyright © 2010 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works.

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Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Physician supply and demand / editor, Adam Berényi. p. ; cm. Includes bibliographical references and index.

ISBN:  (eBook)

1. Physicians--Supply and demand--United States. I. Berényi, Adam. [DNLM: 1. Health Manpower--trends--United States. 2. Physicians--supply & distribution--United States. 3. Education, Medical, Graduate--trends--United States. W 76 P5783 2009] RA410.7.P472 2009 338.4'761--dc22 2009044337

Published by Nova Science Publishers, Inc.  New York

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CONTENTS Preface

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Chapter 1

xi Graduate Medical Education: Trends in Training and Student Debt Government Accountability Office

Chapter 2

Physician Supply and Demand: Projections to 2020 United States Department of Health

Chapter 3

Primary Care Professionals: Recent Supply Trends, Projections and Valuation of Services Government Accountability Office

1 39

83

Chapter Sources

103

Index

105

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PREFACE The United States continues to debate the adequacy of the current and future supply of physicians. This book presents projections of physician supply and requirements for 18 physician specialties using the Physician Supply Model (PSM) and the Physician Requirements Model (PRM) developed by the Health Resources and Services Administration (HRSA). This book also focuses on recent supply trends for primary care professionals, including information on training and demographic characteristics. Projections of future supply for primary care professionals, including the factors underlying these projections are examined, as well as the influence of the health care system's financing mechanisms on the valuation of primary care services.This book consists of public documents which have been located, gathered, combined, reformatted, and enhanced with a subject index, selectively edited and bound to provide easy access. Chapter 1 - This is an edited, reformatted and augmented version of a United States Government Accountability Office, Graduate Medical Education Staff Briefing, dated May 4, 2009. Chapter 2 - The United States continues to debate the adequacy of the current and future supply of physicians. While the general consensus is that overall physician supply per capita will remain relatively stable over the next 15 years, there is less agreement on future demand for physician services. This paper presents projections of physician supply and requirements for 18 physician specialties using the Physician Supply Model (PSM) and the Physician Requirements Model (PRM) developed by the Health Resources and Services Administration (HRSA). In this paper, we describe the data, assumptions and methods used to project the future supply of and requirements for physician services; we present projections from these models under alternative scenarios;

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xii

Adam Berényi

and we discuss the implications of these projections for the future adequacy of physician supply. Accurate projections of physician supply and requirements help preserve a physician supply that is balanced with demand and help the Nation achieve its goal of ensuring access to high-quality, cost-effective healthcare. The length of time needed to train physicians, as well as the time needed to change the Nation’s training infrastructure, suggests that we must know at least a decade in advance of major shifts in physician supply or requirements. The U.S. Government Accountability Office noted in their February 2006 report "Health Professions Education Programs – Action Still Needed to Measure Impact," that regular reassessment of future health workforce supply and demand is key to setting policies as the Nation’s health care needs change. Past projections of impending physician shortages and surpluses have influenced policies and programs that, in turn, helped determine the number and specialty composition of physicians being trained. During the 1950s and 1960s, projections of a growing physician shortage helped motivate an expansion of the Nation’s medical schools, an increase in government funding for medical education, and the creation of policies and programs that encouraged immigration of foreign-trained physicians. Efforts to increase the physician supply proved so successful that, by the late 1970s, many predicted a growing oversupply of physicians (GMENAC, 1981). Rising healthcare costs paved the way for managed care and its promises to improve the efficiency of the healthcare system. Enrollment in health maintenance organizations (HMOs) during the 1980s and 1990s prompted reexamination of physician supply adequacy. The greater reliance of HMOs on the use of generalists and the prediction of decreased use of specialist services under managed care led to projections that the United States would have a large surplus of specialists (e.g., COGME, 1992, 1994; Weiner, 1994; IOM, 1996). However, the perceived limitations of the more restrictive forms of managed care prompted a public backlash against many of the forces predicted to decrease healthcare use. Also, some researchers have argued that physician projections that relied heavily on HMO staffing patterns underestimated physician requirements by failing to adequately control for out-of-plan care (Hart et al., 1997) and systematic differences in the health status of the population enrolled in HMOs and the population receiving care under a traditional fee-for-service arrangement. Cooper et al. (2002) contributed to another round of discussions regarding the adequacy of the future supply of physicians projecting a significant shortage of physicians—particularly specialists—over the foreseeable future. Other researchers have expressed concerns with the assumptions and conclusions used

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Preface

xiii

by Cooper et al. (Barer, 2002; Grumbach, 2002; Reinhardt, 2002; Weiner, 2002), but a growing consensus is that over the next 15 years, requirements for physician services will grow faster than supply—especially for specialist services and specialties that predominately serve the elderly. COGME joined the debate using preliminary projections from BHPr’s PSM and PRM, adjusted for COGME’s assumptions regarding the effects of key determinants of supply and requirements, projecting a modest shortfall of physicians by 2020. These projections helped influence the Association of American Medical Colleges (AAMC) decision to encourage growth in the Nation’s medical school training capacity by approximately 15 percent (or 3,000 physicians per year). The primary contributions of our study are (1) projections of overall physician supply and requirements to inform the debate on the Nation’s medical school capacity, and (2) specialty-specific projections of physician supply and requirements under alternative scenarios. Chapter 3 - Most of the funding for programs under title VII of the Public Health Service Act goes toward primary care medicine and dentistry training and increasing medical student diversity. Despite a longstanding objective of title VII to increase the total supply of primary care professionals, health care marketplace signals suggest an undervaluing of primary care medicine, creating a concern about the future supply of primary care professionals—physicians, physician assistants, nurse practitioners, and dentists. This concern comes at a time when there is growing recognition that greater use of primary care services and less reliance on specialty services can lead to better health outcomes at lower cost. GAO was asked to focus on (1) recent supply trends for primary care professionals, including information on training and demographic characteristics; (2) projections of future supply for primary care professionals, including the factors underlying these projections; and (3) the influence of the health care system’s financing mechanisms on the valuation of primary care services. GAO obtained data from the Health Resources and Services Administration (HRSA) and organizations representing primary care professionals. GAO also reviewed relevant literature and position statements of these organizations.

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In: Physician Supply and Demand Editors: Adam Berényi

ISBN: 978-1-60876-130-2 © 2010 Nova Science Publishers, Inc.

Chapter 1

GRADUATE MEDICAL EDUCATION: TRENDS IN TRAINING AND STUDENT DEBT Government Accountability Office

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May 4, 2009 The Honorable George Miller Chairman The Honorable Howard P. ―Buck‖ McKeon Ranking Member Committee on Education and Labor House of Representatives The Honorable Robert Andrews Chairman Subcommittee on Health, Employment, Labor and Pensions Committee on Education and Labor House of Representatives The Honorable Charles W. Boustany, Jr. The Honorable Joe Courtney The Honorable Tom Price House of Representatives

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Government Accountability Office

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Subject: Graduate Medical Education: Trends in Training and Student Debt The federal government invests significantly in medical education through various programs to help ensure that the anticipated supply of new physicians meets the nation’s health care needs. Medicare, the federal health care program for elderly and certain disabled people, subsidizes training for medical school graduates in hospitals and other teaching institutions by helping to support the increased costs associated with postgraduate medical training. These subsidy payments provided hospitals and other teaching institutions with an additional $8.76 billion1 for postgraduate medical training in fiscal year 2008.2 In addition, Medicaid, a joint federal and state program that finances health care for certain low-income individuals, provides funding for graduate medical education.3 In order to pay for medical school tuition and related fees, students often rely on loans to finance their education. The Department of Education (Education) administers loan programs that are available to medical school students.4 These loans may be made by private lenders and guaranteed by the federal government or made directly by the federal government through a student’s school. The Health Resources and Services Administration (HRSA) administers various scholarships, loans, and loan repayment programs for disadvantaged students and those committing to practice in underserved areas or train in specific specialties.5 In addition, the Department of Veterans Affairs provides funding and training opportunities for new physicians in its medical facilities.6 Students must complete an undergraduate education and typically 4 years of medical school, at which point they earn a medical degree and become physicians. By their last year of medical school, students typically choose a specialty in which they will undertake required postgraduate medical training, known as residency, in order to practice medicine without supervision. Most specialties can fall into three general categories: primary care, surgical, and procedural. Most students apply for residency through the National Resident Matching Program (NRMP),7 which matches applicants with residency programs based on the preferences of both parties.8 However, because more students apply for some specialties than positions are available, some students may not receive a position in their preferred specialty. Residency can last 3 to 5 years, depending on the specialty. After residency, some physicians may decide to pursue further postgraduate medical training, known as a fellowship, in order to become a subspecialist. For example, to become a cardiologist, a medical school graduate must complete an internal medicine residency

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Graduate Medical Education: Trends in Training and Student Debt

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followed by a cardiology fellowship. In some cases, depending on the specialty or subspecialty, a physician could spend 7 or more years in postgraduate medical training. You asked us to provide information on graduate medical education. Specifically, we focused on (1) trends in postgraduate medical training, (2) factors that influence medical students’ specialty choice, and (3) trends in the amounts of student debt incurred by medical school graduates. Enclosure I contains information on graduate medical education. You also asked us to provide information on trends in postgraduate dental education and student debt and thoracic surgery fellowships; that information can be found at enclosures II and III, respectively. To examine trends in postgraduate medical training, we reviewed relevant academic and professional literature and analyzed data on residency offered, student preferences, and residency placements from 1998 to 2008.9 We also interviewed officials and reviewed information or documents from the Centers for Medicare & Medicaid Services (CMS), the agency that oversees the Medicare program; the Medicare Payment Advisory Commission; HRSA; and professional organizations, including groups that represent medical schools, medical students, and physicians. To examine factors that influence medical students’ specialty choice, we reviewed relevant academic and professional literature and examined a survey of 4th year medical students developed by the Association of American Medical Colleges (AAMC).10 We also interviewed officials from professional organizations, including groups that represent medical schools, medical students, and physicians. To examine trends in medical student debt, we analyzed self-reported student indebtedness data from the AAMC survey of 4th year medical students from 1998 to 2008. We also examined data on medical school tuition and fees from an AAMC survey of medical schools and physician salaries collected by the Medical Group Management Association (MGMA). We also interviewed federal officials and reviewed relevant agency guidance to identify the types of federal loans and repayment plans that are available to medical students. We discussed the NRMP, AAMC, and MGMA data sources with knowledgeable officials and determined that the data were sufficiently reliable for our purposes. (See encl. IV for a more detailed description of our scope and methodology.) We conducted our work from September 2008 to April 2009 in accordance with all sections of GAO’s Quality Assurance Framework relevant to our objectives. The framework requires that we plan and perform the engagement to obtain sufficient and appropriate evidence to meet our stated objectives and discuss any limitations in our work. We believe that the

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Government Accountability Office

information and data obtained, and the analysis conducted, provide a reasonable basis for any findings and conclusions. In summary, we found that medical students prefer surgical and procedural specialties, and physician subspecialization is increasing. Relative to the number of available residency positions, more medical students have preferred surgical and procedural specialties over primary care specialties since 1999, according to national data. As a result, surgical and procedural specialties have been more competitive than primary care specialties. Students earning an MD degree from U.S. medical schools fill higher proportions of the more competitive surgical and procedural residency positions than students earning a DO degree and students graduating from international medical schools. In addition, the percentage of physicians pursuing subspecialty training grew from 2002 to 2007, according to national data. This trend was observed in fields such as orthopedic surgery (a surgical subspecialty), anesthesiology (a procedural specialty), and family medicine (a primary care specialty). Multiple factors and demographic characteristics influence students’ specialty choice. While there is no consensus on the most influential factors affecting specialty choice, students consider various factors either individually or in concert when selecting a specialty, according to multiple sources, including published literature, a 2008 AAMC survey, and experts we interviewed. For example, students may consider their intellectual interest in the specialty, their exposure to the specialty, or the prestige of the specialty when making their specialty choice. Some factors may also lead students to pursue certain specialties while avoiding others. For example, the desire for a controllable lifestyle—a predictable schedule and fewer on-call hours11—and high salary may lead students to pursue procedural specialties such as anesthesiology, and avoid other specialties such as primary care. Demographic characteristics such as gender and marital status are associated with students being more likely to enter certain specialties. For instance, married students are more likely to select primary care specialties and women are more likely to select obstetrics and gynecology and less likely to choose surgery. Although medical student debt is rising, physicians are eligible for federal loan repayment relief plans during postgraduate medical training and can eventually earn high incomes that can be used to repay their loans. Medical school tuition and fees have increased significantly since 1998. Medical students can borrow up to $40,500 per year through the federal Stafford loan program12 with additional funding available through other federal loan programs; these loan programs can cover the full cost of medical school. The

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median amount of educational debt for indebted medical students graduating in 2008 was $155,000—a 53 percent increase since 1998, controlling for inflation. Once out of medical school, residents earn stipends—on average about $3,729 a month for a 1st year resident. With $155,000 in debt, a resident’s monthly loan payment could reach over $1,700 (about 48 percent of pretax income). However, residents have repayment options that can reduce their monthly debt payment until they complete postgraduate training. One option that will be available to borrowers after July 1, 2009, would cap the average 1st year resident’s loan payments at about $364 month while a second option—forbearance—allows for a temporary postponement or reduction in loan payments. Physicians generally do not qualify for these options once postgraduate training is complete because, although they incur more debt than other advanced degree holders, they also earn higher incomes. We provided a draft of this report to the Deparment of Health and Human Services (HHS), the department that oversees CMS and HRSA; Education; and AAMC. HHS’s written comments are reprinted in enclosure V. HHS, Education, and AAMC also provided technical comments, which we incorporated as appropriate. HHS remarked that GAO reported an increase in the specialty choice of family medicine by U.S. medical school graduates. However, we did not state this in our report; rather, we noted that physician subspecialization was generally increasing and that this trend was observed within several specialties, including family medicine. In other words, the incidence of physicians who have already chosen family medicine as their specialty but pursue additional training beyond initial residency has increased. As we noted in our analysis of U.S. MD student preferences relative to positions available, primary care specialties, which include family medicine, have been less popular than surgical and procedural specialties. HHS also commented that service obligation—that is, a requirement that physicians practice in a specific field of medicine under certain conditions in exchange for benefits, such as educational scholarships or loan repayment—is an additional factor that potentially influences specialty choice.13 For example, medical students can apply to HHS’s National Health Service Corps (NHSC) Scholarship Program to receive funds14 if they agree to complete a primary care residency and practice in an underserved area after residency. The NHSC also offers a loan repayment program for primary care physicians practicing in an underserved area. In our report, we focused on broad, underlying factors that affect students’ specialty choice rather than specific contractual obligations.

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Government Accountability Office

Providing oral comments on a draft of this report, the AAMC largely agreed with our findings and noted that the report captured the complexities of medical students’ decision making in choosing a specialty. It also added several relevant points. First, additional demographic characteristics, such as the geographic background (e.g., urban or rural) and the socioeconomic status of the medical student and his or her family, are associated with specialty choice. It added that debt does not appear to significantly influence specialty choice, which is consistent with our findings. Second, entry rates for various specialties are influenced by numerous factors, including the prevailing market conditions and environment. As a result, it noted, trends in specialty choice often shift and have been cyclical over time. For example, primary care specialties were more popular in the mid 1990s when managed care was introduced and the anticipated demand was high. And third, there is an emerging trend of physicians who provide general medical care only in hospitals where they may often work set shifts instead of being on call. The trend, which is particularly associated with physicians specializing in internal medicine (but not subspecializing), limits the number of physicians providing primary care services in traditional settings, such as physicians’ offices and health clinics. In addition, the AAMC raised concerns about including neurology and pathology in our procedural specialties category. It suggested that we consider categorizing them as ―cognitive‖ or ―other‖ specialties. While we did not create another category for these specialties, when we conducted an additional analysis that removed them from the procedural specialties category in our preferences-to-positions ratio analysis, we found that their exclusion did not change the trend for procedural specialties from 1998 to 2008.

Kathleen M. King Director, Health Care

George A. Scott Director, Education, Workforce, and Income Security Issues Enclosures – 6

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Graduate Medical Education: Trends in Training and Student Debt

ENCLOSURE I Graduate Medical Education: Trends in Training and Student Debt Briefing for the Staff of: The Honorable George Miller Chairman The Honorable Howard P. "Buck" McKeon Ranking Member Committee on Education and Labor House of Representatives

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The Honorable Robert Andrews Chairman Subcommittee on Health, Employment, Labor and Pensions Committee on Education and Labor House of Representatives The Honorable Charles W. Boustany, Jr. The Honorable Joe Courtney The Honorable Tom Price House of Representatives

Overview Introduction Objectives Scope and Methodology Background Results

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Government Accountability Office

Introduction The federal government invests significantly in medical education to help ensure that the anticipated supply of new physicians meets future health care needs. Federal government support includes: Medicare payments, which provided about $8.7 billion to hospitals and other institutions for medical training in fiscal year 2008. Medicaid payments, which provided nearly $3.2 billion in 2005. Student loans, tuition assistance, and student loan repayment. Training opportunities at federal facilities. The road to becoming a doctor can be long and costly

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Objectives 1. Describe the trends in postgraduate medical training. 2. Describe the factors that influence medical school students’ specialty choice. 3. Describe the trends in the amounts of student debt incurred by medical school graduates.

Source: GAO.

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Scope and Methodology We reviewed relevant literature published from 1998 to 2008 from: 16 research databases 162 articles on residency trends, factors affecting specialty choice, and student debt We interviewed officials and reviewed information or documents from: Centers for Medicare & Medicaid Services Health Resources and Services Administration Department of Education Medicare Payment Advisory Commission Professional organizations, including groups that represent medical schools, medical students, and physicians We reviewed and analyzed publicly available data, including: National Resident Matching Program (NRMP) data for 19982008 on residency positions offered, student preferences, and placements. The NRMP matches applicants with residency programs. Association of American Medical Colleges (AAMC) survey of 4th year medical students, called the Graduation Questionnaire, which covers factors that may affect specialty choice. It also contains information on student debt. Medical Group Management Association (MG MA) Physician Compensation and Production Survey data on median annual earnings for various medical specialties.

Background Medical education U.S. medical school enrollment has grown. In 2008, over 22,500 1st year students were enrolled, an all-time high. Eligible applicants for U.S. postgraduate medical training programs include:

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Government Accountability Office Doctor of Medicine (MD) students graduating from a U.S. medical school.

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Doctor of Osteopathic Medicine (DO) students graduating from a U.S. osteopathic medical school. International medical school students, who can be U.S. citizens or non-U.S. citizens graduating from a foreign medical school. The length of residency training varies depending on the specialty chosen. Three years for primary care fields, such as family medicine, general internal medicine, and general pediatrics. Five years for general surgery. Fellowship training to become a subspecialist can add one or more years. To become a cardiothoracic surgeon, a medical school graduate must complete a general surgery residency followed by a cardiothoracic surgery fellowship. To become a cardiologist, a medical school graduate must complete an internal medicine residency followed by a cardiology fellowship.

Source: AAMC and the American Medical Association (AMA) Percentage of Physicians in Postgraduate Medical Training by School Type -2007

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Postgraduate medical training generally occurs at hospitals, medical centers, and Veterans Affairs facilities. Each program determines how many residents or fellows it would like to train. Most postgraduate training programs are accredited by the Accreditation Council for Graduate Medical Education (ACGME), which evaluates a program’s ability to adequately train the desired number of residents by considering the program’s facilities, faculty size, and other factors.

Key Policy Changes in Postgraduate Medical Training In part to constrain costs, Congress limited the number of postgraduate medical training positions supported by Medicare with the 1997 Balanced Budget Act. In 2003, ACGME implemented a limit on resident and fellow duty hours during postgraduate medical training due to concerns regarding residents’ and fellows’ work schedules and patient safety. Duty hours must be limited to 80 hours per week and 1 day out of 7 days must be free from all educational and clinical obligations.

Federal student loans Loans available to students pursuing higher education: Stafford Loans—the government’s largest student loan program.

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Government Accountability Office Depending on the student’s financial need, these loans can be subsidized (the government pays interest while the student is in school) or unsubsidized. PLUS Loans—provide more funding for graduate students who have met their maximum Stafford loan eligibility. Perkins Loans—low-interest rate loans for students with exceptional financial need. Low-interest rate loans available to students in health professions: Loans for Disadvantaged Students—for students from disadvantaged backgrounds. Primary Care Loans—for students who agree to practice in primary care.

Most specialties can fall into three categories Primary care specialties include family general internal medicine, and general pediatrics.

medicine,

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Surgical specialties include general surgery, and subspecialties in orthopedic, plastic, and thoracic surgery. Procedural specialties include radiology, dermatology, and anesthesiology, as well as subspecialties in cardiology, rheumatology, and immunology.

Summary of Findings 1. Medical students prefer surgical and procedural specialties, and are more likely to subspecialize. 2. Multiple factors and demographic characteristics influence specialty choice. 3. Although medical student debt is rising, federal loan repayment relief plans offer assistance during training and physicians can earn high incomes that can be used to repay their loans.

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1. Surgical and Procedural Specialties Preferred, and Subspecialization Increasing Surgical and Procedural Specialties Have Been More Competitive

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Since 1999—after accounting for the number of positions available— more U.S. MD students have preferred surgical and procedural specialties over primary care specialties, according to national data. Because more students prefer surgical and procedural specialties relative to the number of available positions, these specialties have been more competitive. Since 2004, surgical specialties have been the most competitive.

Source: GAO analysis of NRMP data. Number of U.S. MD Student Applicants who Prefer the Specialty Group Relative to the Number of Available Positions in the Specialty Group, 1998-2008

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U.S. MD students fill higher proportions of available surgical and procedural positions

Note: Bars do not add to 100 percent because other student groups, such as previous U.S. MD graduates and Canadian students, are not included. Source: GAO analysis of NRMP data.

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NRMP Positions Filled by Applicant Type, 2008

Source: AAMC and AMA. Note: Internal medicine excludes the sub-subspecialties of clinical cardiac electrophysiology and interventional cardiology. Change in Subspecialization Rates for Selected Specialties or Subspecialties

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More doctors are pursuing training to become subspecialists Across selected specialties, the percentage of physicians subspecializing grew from 2002 to 2007, according to national data. This trend was also observed for family medicine. The majority of newly accredited programs in recent years are for training in subspecialties, according to ACGME officials. In contrast, the number of newly accredited programs for initial residency training has been relatively stable.

2. Multiple Factors, Demographic Characteristics Influence Specialty Choice

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Students consider multiple factors Students consider multiple factors—individually or in concert—when choosing a specialty, as suggested by published literature, a 2008 AAMC survey, and experts. While there is no consensus regarding the most influential factors, there are several commonly cited factors, including...

Source: GAO.

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Factors lead students to pursue or avoid certain specialties Intellectual interest in the specialty Students are attracted to rheumatology because they are interested in the complexity of diseases treated by rheumatologists. Some students do not choose primary care specialties because they prefer to focus in a specialized area of medicine. Exposure to specialties in medical school Students who had a community-based primary care experience during medical school were more likely to select a primary care specialty. Students may be less likely to select surgery because they found their surgical work repetitive during medical school. Prestige Students view surgery as prestigious while primary care specialties may not be considered as prestigious. Salary and lifestyle Procedural specialties, with generally higher salaries and a more controllable lifestyle, may be more attractive. An anesthesiologist earns about $400,000 a year, according to the MG MA, and can have a predictable schedule with fewer on-call hours. Primary care specialties, with generally lower salaries and a less controllable lifestyle, may be less attractive. A family medicine physician earns about $174,000 a year, according to the MGMA, and can have a less predictable schedule with more on-call hours.

Demographics and personality traits are important Demographics—such as marital status and gender—and personality traits may be associated with specialty choice, according to published studies. Married students are more likely to enter primary care specialties such as pediatrics and family practice. Women are more likely to choose primary care and obstetrics and gynecology, but less likely to choose surgery.

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Personality traits, such as altruism, may lead some to select primary care specialties, while students who have competitive personalities may select surgery.

3. Debt Is Rising but Federal Assistance Is Available and Physicians Can Earn High Incomes

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Median debt of indebted graduating U.S. MD students has increased by 53 percent since 1998, controlling for inflation. The median level of debt among indebted U.S. MD students graduating in 2008 was $155,000.

Source: AAMC. Median Educational Debt for Indebted Graduating U.S. MD Students, 1998-2008

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Debt, Federal Assistance, Physician Income

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Nearly half of graduating medical students are at least $150,000 in debt

Source: AAMC. Distribution of Student Debt Among U.S. MD Students Graduating in 2008

Medical school tuition is also increasing Median tuition and fees for 1st year U.S. MD students have increased by about $9,100 at private schools (27 percent) and about $10,500 at public schools (83 percent) since the 1997-1998 school year, controlling for inflation. Undergraduate tuition and fees have also increased. In the 2007-2008 school year, median tuition and fees for 1st year U.S. MD students ranged from approximately: $23,000 at public schools (in-state residents) to $43,000 at private schools (out-of- state residents)

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Source: AAMC. Median Tuition and Fees for First-Year U.S. MD Students, 1998-2008 2008

Federal loans are available to cover the full cost of medical education Stafford loans—medical students can borrow up to $40,500 a year, with an aggregate limit of $224,000 (including undergraduate loans). The annual limit is $20,000 more than other students can borrow. The aggregate limit is $85,500 more than other students can borrow. The Department of Education increased the aggregate loan limit for medical students from $189,125 to $224,000 in April 2008. PLUS loans—graduate and professional degree students can borrow up to the full cost of attendance minus other federal assistance.

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Source: GAO.

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Options for reducing repayment burdens until after training Borrowers generally must start repaying their loans within 6 months of graduation. With $155,000 in debt, a resident’s monthly loan payment could reach over $1,700 per month. Since the average 1st year resident stipend is $3,729, these payments would account for about 48 percent of pretax income. Repayment relief options: 20/220 Pathway (available until June 30, 2009)—a temporary deferment of loan payments for students with high debt relative to income. Eligible residents can defer all federal loan payments without accruing interest on subsidized loans. Income-based repayment plan (available after July 1, 2009)—a graduated repayment plan for students with high debt relative to income. Caps the average 1st year resident’s loan payments at $364 per month (about 10 percent of pretax income).

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Forbearance—a temporary postponement or reduction in loan payments. Residents are automatically eligible, but interest continues to accrue on all loans and is added to the principal. As a result, the amount due on the loans is larger than it would be if residents had not sought forbearance. After postgraduate training is complete, physician income typically increases significantly. At this higher income level, borrowers generally do not qualify for repayment relief options.

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Physicians incur more debt but can earn high incomes to repay it

Source: GAO analysis based on data from the AAMC, MGMA, National Postsecondary Student Aid Study, and Census Bureau. * Due to the way MGMA data is reported, the specialties included in this calculation are somewhat different from the procedural and surgical categories used in earlier slides. Median Income and Debt by Degree, 2007

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ENCLOSURE II Trends in Postgraduate Dental Education and Student Debt

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Unlike physicians, dentists are generally not required to complete postgraduate training, but may instead practice after graduating from a 4-year dental school and completion of licensure requirements, according to the American Dental Association (ADA). However, dentists may choose to pursue postgraduate training through a general or specialty dental program. General dentistry programs last 1 or 2 years and are affiliated with dental schools, which typically offer advanced education in general dentistry (AEGD) programs, or hospitals, which typically offer general practice residency (GPR) programs. Specialty dental programs allow a dentist to train in one of several specialties—endodontics, orthodontics and dentofacial orthopedics, oral and maxillofacial surgery, oral and maxillofacial radiology, oral and maxillofacial pathology, periodontics, pediatric dentistry, prosthodontics, or public health dentistry. Many of these programs last from 1 to 3 years.15 Some specialty programs also include graduate-level coursework leading to an additional degree.

Source: ADEA. Figure 1. Dental Students’ Career or Academic Plans Following Graduation, 19952006.

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This enclosure describes: (1) trends in postgraduate dental training, (2) factors that influence dental school graduates’ choice to pursue postgraduate training, and (3) trends in debt for graduating dental students. We relied on multiple methodologies to conduct our work, including data analysis, literature review, and interviews with experts in dental education, such as the ADA and the American Dental Education Association (ADEA). (See encl. IV for a detailed description of the scope and methodology.) The percentage of graduating students planning to pursue postgraduate dental training was stable from 1995 to 2006, according to ADEA data (see figure 1). While most dental school seniors planned to go directly into private practice, almost 40 percent planned to pursue postgraduate dental training. The rest planned to go into teaching, research, administration, government service, or were undecided. The percentage of graduating seniors applying to general programs remained stable at about 30 percent from 1996 to 2006. The percentage of those applying to specialty programs grew from about 18 percent in 1996 to about 24 percent in 2006—over a 30 percent increase in the percentage of students applying to specialty programs over a 10- year period (see Figure 2). Despite the increase in the percentage of students applying to specialty programs between 1996 and 2006, ADA data show that the proportion of specialists in the dental workforce remained close to 20 percent from 1991 through 2005. According to 2006 ADEA data, orthodontics was the most popular dental specialty (about 32 percent of specialty program applicants), followed by pediatric dentistry (about 24 percent) and oral and maxillofacial surgery (about 17 percent). Dentists often choose to pursue postgraduate dental training because of personal interest in the content of a program, according to research studies and experts. For example, dentists may be interested in the intellectual content, diagnostic challenges, or the skills and talents required for a particular specialty. Experts also indicated that competitiveness—the applicant’s ability to obtain a training position—influences whether a student applies for postgraduate dental training. Data from the 2006 ADEA survey of graduating dental school seniors show that debt influences their postgraduate plans—22 percent noted it as a major influence on their decision.

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Source: ADEA. Figure 2. Percentage of Dental Students Applying for General Programs or Specialty Programs, 1996-2006.

Dental student debt is rising. In 2006, the average indebtedness of all graduating dental students was $145,465—up about 55 percent from 1996, after controlling for inflation— according to ADEA data. Average tuition and fees for 1st year dental students was $29,717 for the 2006-2007 school year— up about 40 percent from the 1997-1998 school year, after controlling for inflation—according to ADA data. Average tuition and fees for the 2006-2007 school year were $17,866 for public dental schools and $41,568 for private dental schools. Average tuition and fees for the 1997-1998 school year were $8,529 for public dental schools and $25,798 for private dental schools. Like physicians in residency, dentists can qualify for the same loan repayment relief options—income-based repayment plans and forbearance— while they are completing their postgraduate dental training.16 In addition, like physicians, dentists can earn high incomes once their training is complete. In 2005, the average salary was $198,350 for general dentists, and $304,020 for dentists who specialized, according to the ADA.

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ENCLOSURE III Trends in Thoracic Surgery Fellowships

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Thoracic surgery fellowships are an exception to the generally increasing rate of subspecialization among physicians. Forty percent fewer physicians applied for 2008 thoracic surgery fellowship positions than those applying for 2004 positions, according to national data (see Figure 3). Moreover, less than 67 percent of 2008 positions were filled, down from 94 percent of 2004 positions (see figure 4). (See encl. IV for a detailed description of our scope and methodology.)

Source: NRMP. Notes: Years refer to the year of appointment, that is, the year the physician begins his or her fellowship. Includes only surg ical subspecialties for which 2004 and 2008 data were available. Figure 3. Number of Fellowship Applicants for Selected National Resident Matching Program (NRMP) Surgical Subspecialties, 2004 and 2008

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Source: NRMP Notes: Years refer to the year of appointment, that is, the year the physician begins his or he r fellowship. Includes only surgical subspecialties for which 2004 and 2008 data were available. Figure 4. Percentage of Fellowship Positions Filled for Selected NRMP Surgical Subspecialties, 2004 and 2008

Published articles suggest that fewer employment opportunities for thoracic surgeons may be contributing to the declining interest in thoracic surgery fellowships. For example, some thoracic surgeons may need an additional fellowship focusing on a narrower area of thoracic surgery, such as adult cardiac surgery, to secure employment. Another reason for the decline, according to experts, may be due to the growing use of nonsurgical treatments for cardiovascular disease, such as stents17, that are not performed by thoracic surgeons.

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ENCLOSURE IV Scope and Methodology

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Our review focused primarily on medical students enrolled in U.S. medical schools leading to the degree of Doctor of Medicine (MD) and allopathic18 postgraduate medical training.19 To conduct our work, we relied on multiple methodologies, including analyses of summary data, literature reviews, and interviews.

Data Analysis To examine trends in postgraduate medical training, we examined National Resident Matching Program (NRMP) data for 1998 to 2008. The NRMP administers a service—known as the match—that matches applicants with residency programs based on the ranked preferences of both parties.20 The NRMP collects and maintains data on the number of applicants, the type of applicants’ medical school,21 the applicants’ preferred specialty (their first or only choice), and the specialty in which the applicant placed. According to the NRMP, the match fills about 80 percent of all residency positions. NRMP is the most comprehensive data source on student preferences and available residency positions. In addition, U.S. MD students are required to enter the match when applying for residency.22 In 2008, 28,737 applicants applied to the match and 23,674 were successfully matched to a position. NRMP data are publicly available on the NRMP Web site. To examine trends in U.S. MD students’ preferences, we calculated a ratio of the number of U.S. MD student applicants who preferred primary care, surgical, or procedural specialties to the number of 1st and 2nd year residency positions available in each specialty group. (See table 1 for the NRMP specialties and subspecialties categorized under the primary care,23 surgical, and procedural specialty groups; the numbers of student preference and available positions; and the ratio of student preferences to positions.) To determine the proportion of U.S. MD students, DO students, and international medical students that filled surgical, procedural, and primary care positions in 2008, we divided the number of students from each type of medical school that had received a position in primary care, surgical, or procedural specialties by the number of 1st and 2nd year positions available in each specialty group. (See table 2 for the number of students that filled each specialty category.)

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Total

Ratio, preferences to positions (2008)

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Procedural

Number of positions available (2008)

Surgical

family medicine internal medicine pediatrics general surgery neurological surgery orthopedic surgery plastic surgery otolaryngology urology Anesthesiology dermatology emergency medicine neurology radiology radiation oncology pathology physical medicine and rehabilitation

Number of U.S. MD student applicants who expressed the specialty category as a preferred choice (2008)

Primary care

NRMP specialties/ subspecialties

Category

Table 1. Categories of NRMP Specialties and Subspecialties and U.S. MD Student NRMP Preferences and Positions Available in 2008

5,992

10,643

0.56

2,217

2,093

1.06

4,605

5,831

0.79

12,814

18,567

N/A

Source: GAO and GAO analysis of NRMP data. Notes: NRMP included combined internal medicine and pediatrics programs in its preference data; however, NRMP does not consider preliminary or transitional year programs a preference for a specific specialty, and therefore they were excluded from its preference data. We grouped NRMP applicants into three specialty categories, and therefore did not include all NRMP applicants in our analysis. We also did not include specialties or subspecialties with fewer than 10 NRMP positions (with the exception of combined programs, which NRMP included under internal medicine and pediatrics accordingly). In addition, obstetrics/gynecology and psychiatry were not included because of debate within the industry about whether they are considered primary care specialties. However, including them in our preferences-to-positions ratio did not change the trend for primary care specialties from 1998 to 2008. In providing comments on our report, AAMC stated that neurology and pathology are not typically considered procedural specialties. When we conducted an additional analysis that removed them from the procedural specialties category in our preferences-to-positions ratio analysis, we found that their exclusion did not change the trend for procedural specialties from 1998 to 2008.

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Table 2. Number of U.S. MD, DO, and International Medical Students that Filled Each Specialty Category in 2008 Category Primary care Surgical Procedural Total

U.S. MD students 5,926 1,843 4,287 12,056

DO students 784 34 449 1,267

International medical students 3,207 133 596 3,936

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Source: GAO analysis of NRMP data. Notes: For purposes of consistency, we excluded the same programs and specialties or subspecialties as we did in our preferences-to-positions ratio analysis; we also excluded combined programs with less than 10 NRMP positions and those in which the first specialty mentioned was not included in our original definitions of primary care, surgical, and procedural.

To examine factors that influence specialty choice, we reviewed data from AAMC’s Graduation Questionnaire (GQ). The data are available on the AAMC Web site. The GQ is an annual survey of 4th year MD students at U.S. medical schools. The survey asks students to rate the importance of factors that influence their specialty choice; students do not rank the factors in order of importance. We examined data from 2005 to 2008 because the factors listed in the survey for these years were considered to be comparable by AAMC officials. The response rate for the survey for these years ranged from 33 percent in 2005 to 71 percent in 2008.24 Despite the variation in the response rates from 2005 to 2008, our analysis generally revealed little change in the influence of the factors on specialty choice. We therefore only reported data for 2008. To examine trends in student debt, we reviewed median summary data for 1998 to 2008 from the GQ published in the AAMC Data Book: Medical Schools and Teaching Hospitals by the Numbers (May 2008 edition), also available on the AAMC Web site.25 The GQ asks 4th year medical students about their outstanding loans for both medical school and undergraduate education. The data are self-reported near the time of students’ exit interviews with their financial aid office, when they are informed of their debt levels. The overall response rate for the survey has ranged from 33 percent to 92 percent since 1998, but this variation does not appear to have resulted in any year-toyear irregularity in the data. To validate the GQ debt data, AAMC officials compare the aggregate student-reported data with administrative records from medical school financial aid offices. The AAMC debt data are widely used

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because they are the most comprehensive available. Further, we also compared the AAMC data with data obtained from Education’s National Postsecondary Student Aid Study (NPSAS) of 2000 and 2004. The comprehensive, nationwide NPSAS is designed to determine how students and their families pay for postsecondary education and includes data on outstanding student loan debt. We determined that average medical student debt levels from the NPSAS were comparable with the AAMC data. We adjusted the historical AAMC debt data for inflation using the gross domestic product price index. We also calculated estimated monthly loan payments for medical school graduates using the median level of student indebtedness reported by the AAMC. Our calculation was based on the assumption of a 10-year repayment schedule at the standard Stafford loan interest rate of 6.8 percent. Our calculated loan payments corresponded with estimates produced with Education’s repayment plan calculator available on its Web site.26 To examine medical school tuition and fees, we examined data from the AAMC Tuition and Student Fees Survey of allopathic medical schools, published in the AAMC Data Book: Medical Schools and Teaching Hospitals by the Numbers. We adjusted the AAMC median historical data for inflation using the gross domestic product price index. To create an example of an annual medical student budget, we examined cost of attendance estimates from the five medical schools with the highest tuition and fees according to AAMC. These estimates are developed by each school’s financial aid office and reflect the average estimated cost of attending medical school. To examine the expected income of medical school graduates, we reviewed 2007 data from the Medical Group Management Association’s (MGMA) Physician Compensation and Production Survey: 2008 Report Based on 2007 Data. The report contains the median compensation for physicians by specialty and also overall median compensation for the categories of primary care and specialists. The MGMA category of specialists includes specialties that we considered procedural or surgical specialties (for example, anesthesiology and orthopedic surgery). (See table 1.) It also includes specialties we excluded in our analysis of NRMP data (for example, obstetrics/gynecology) and additional specialties not included in the NRMP data (for example, gastroenterology). (See table 3.) However, because of the way MGMA data were reported, we were unable to recalculate median compensation amounts based solely on the specialties included in our NRMP categories . Therefore, we considered the MGMA category of specialists to correspond roughly to our combined categories of procedural and surgical.

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To collect these data, the MGMA mailed surveys to 9,975 of its member organizations, which include medical group practices and other organizations involved in physician practice management. The response rate was about 20 percent. The MGMA defines compensation to include the amounts reported on W-2, 1099, or K1 (for partnerships) tax forms plus all voluntary salary reductions. The MGMA instructs respondents to include the following sources of compensation: salary, bonus and/or incentive payments, research stipends, honoraria, and distribution of profits. According to MGMA officials, they ensure the reliability of the data by examining them for inconsistencies and comparing them with other industry studies. Although multiple compensation surveys are available, we used the MGMA data because they have been used in many health policy research articles and were recommended by experts we interviewed. In addition, the Centers for Medicare & Medicaid Services uses MGMA compensation data when setting Medicare physician payment rates. To analyze median debt and income for other advanced degree holders, we reviewed debt data from the NPSAS of 2004 and income data from the Census Bureau’s 2008 Current Population Survey (2007 data), the most recent years for which data are available. To account for the different years, we adjusted the 2004 NPSAS data for inflation to 2007 dollars using the gross domestic product price index. The Current Population Survey reports median earnings for full-time workers age 25 and over by educational attainment. These sources provide data on holders of three types of advanced degrees: masters degree (including M.S., M.Ed., and M.B.A.), doctoral degree (e.g., Ph.D.), and professional degree (including M.D. and J.D.), which is required for practicing in certain professions. Table 3. GAO Categories and MGMA Categories and Specialties/Subspecialties GAO category Primary care Procedural and surgical

MGMA category Primary care Specialists

Specialties/subspecialties Family Practice Internal Medicine Anesthesiology Cardiology: Invasive Cardiology: Noninvasive Dermatology Emergency Medicine Gastroenterology Hematology/Oncology Neurology Obstetrics/Gynecology

Source: GAO, MGMA.

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Pediatrics/Adolescent Medicine Ophthalmology Orthopedic Surgery Otorhinolaryngology Psychiatry Pulmonary Medicine Radiology: Diagnostic Surgery: General Urology

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To examine trends in postgraduate dental training, we reviewed publicly available data for 1995 to 2006 from the American Dental Education Association’s (ADEA) Survey of Dental School Seniors. The survey asks about students’ choice to pursue dentistry, educational debt, and postgraduation plans. The response rate was 84 percent in 2006 and about 79 percent from 1995 through 2006. Using the survey data, we created three categories for students’ postgraduation plans: private practice, advanced education, and other. For private practice, we included students who planned to pursue solo private practice, enter a partner or group practice, or begin as an associate or employee of a private practice. For advanced education, we included students who planned to enter general practice residency or advanced education in general or specialty dental programs. For other, we included students who planned to pursue teaching, research or administrative positions, or government service, and those who are undecided. To examine trends in debt for graduating dental students, we reviewed data from the same survey. We adjusted the ADEA historical data for inflation using the gross domestic product price index. The number of U.S. dental school graduates ranged from 3,930 in 1997 to 4,515 in 2006. To examine dental school tuition and fees, we reviewed data from the American Dental Association’s (ADA) 2006-2007 Survey of Dental Education, which contains information on 1st year tuition and fees. All U.S. dental schools are required to complete the survey to maintain their accreditation status. We adjusted the ADA historical data for inflation using the gross domestic product price index. To examine trends in thoracic surgery fellowships, we reviewed publicly available NRMP fellowship data on surgical subspecialties for 2004 and 2008. We included only surgical subspecialties for which 2004 and 2008 data were available. We determined that data from the NRMP, AAMC, MGMA, ADA, and ADEA were sufficiently reliable for our purposes. We assessed the reliability of the NRMP data by interviewing NRMP officials about the residency matching process, data entry procedures, and data accuracy assurance. We assessed the reliability of the AAMC GQ data by interviewing AAMC officials about the survey methodology, response rate, and changes in the data over time. We also corroborated the GQ debt data against similar NPSAS data for selected years. We assessed the reliability of the MGMA data by interviewing MGMA officials about the survey methodology, data entry procedures, and the data accuracy assurance. We assessed the reliability of the ADA and ADEA data by reviewing documentation about the survey

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methodology and the response rates for the ADA Survey of Dental Education and the ADEA Survey of Dental School Seniors.

Literature and Document Review We also reviewed literature published from 1998 to 2008 that included research articles identified through 16 databases such as MEDLINE, PsycINFO, Social SciSearch, and Gale Group Health and Wellness. To examine trends in postgraduate medical training (including thoracic surgery fellowships), we searched ―trends, medical residencies,‖ ―applications, medical residencies,‖ ―trends, physician supply,‖ and other such terms. To examine the factors that influence medical students’ specialty choice, we searched terms such as ―lifestyle,‖ ―salary,‖ ―Medicare payments,‖ ―job market,‖ and ―debt.‖ We also reviewed relevant articles from the annual medical education issue of the Journal of the American Medical Association. We also included in our review articles that were identified by government officials and representatives of professional associations we interviewed. We identified the factors influencing specialty choice by determining those frequently mentioned in the articles we reviewed. We then corroborated that these factors had been mentioned by experts as being influential or were identified as having influenced the specialty choice of most student respondents to the AAMC GQ survey. In all, we reviewed 162 articles. To examine trends in postgraduate medical training and the factors affecting specialty choice, we reviewed information or documents provided to us by the Centers for Medicare & Medicaid Services, Health Resources and Services Administration (HRSA), and the Council on Graduate Medical Education. We also examined documents provided to us by the professional organizations we interviewed. (See below for the full list of government agencies and professional organizations we interviewed.) To identify the types of federal loans and repayment plans available to medical students, we reviewed relevant regulations and guidance from Education and HRSA of the Department of Health and Human Services. We used these documents to evaluate eligibility requirements and the general terms of the loan programs. To provide information on postgraduate dental education and the factors that influence dental specialization, we reviewed research articles that were published from 1998 to 2008. We identified research articles through 18 databases and searched using such terms as ―dental residencies,‖ ―dental specialists,‖ ―salary,‖ ―lifestyle,‖ and ―training‖. We reviewed a total of 28 articles. The articles were used to inform our findings on postgraduate dental

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education and to supplement the information we obtained from experts and publicly available data from the ADA and the ADEA.

Interviews with Government Officials and Professional Groups

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To gather information on medical and dental education and training, we interviewed officials from government agencies and the following professional organizations, including groups that represent medical schools, medical students, and physicians: Accreditation Council of Graduate Medical Education American Association of Colleges of Osteopathic Medicine Association of American Medical Colleges American Academy of Family Physicians American Board of Medical Specialties American College of Surgeons American Dental Association American Dental Education Association American Medical Association American Medical Student Association American Osteopathic Association Centers for Medicare & Medicaid Services Council on Graduate Medical Education27 Department of Education Educational Commission of Foreign Medical Graduates Health Resources and Services Administration Medical Group Management Association Medicare Payment Advisory Commission National Resident Matching Program The Society of Thoracic Surgeons We conducted our work from September 2008 to April 2009 in accordance with all sections of GAO’s Quality Assurance Framework that are relevant to our objectives. The framework requires that we plan and perform the engagement to obtain sufficient and appropriate evidence to meet our stated objectives and discuss any limitations in our work. We believe that the information and data obtained, and the analysis conducted, provide a reasonable basis for any findings and conclusions.

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ENCLOSURE V Comments from the Department of Health and Human Services

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Note: Page numbers in the draft report may differ from those in this report.

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End Notes

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1

These payments include direct and indirect Medicare graduate medical education payments. Direct payments are provided to teaching institutions for costs directly related to medical training, such as teachers’ salaries and administrative costs, while indirect payments are provided for the increased patient care costs associated with medical training. For fiscal year 2008, indirect payments were about 71 percent of total Medicare graduate medical education payments. In addition, Medicare graduate medical payments also subsidize podiatric and dental training. 2 In part to constrain costs, Congress limited the number of postgraduate medical training positions supported by Medicare with the 1997 Balanced Budget Act. Medicare support for podiatric and dental training positions was not affected by this legislation. 3 According to the Congressional Research Service, federal and state Medicaid payments for graduate medical education were estimated to be about $3.2 billion in 2005. This estimate was based on 2005 survey data. There is no formal federal reporting mechanism to document Medicaid graduate medical education payments by state. 4 Medical students received over $1.8 billion in federal guaranteed or direct student loans during the 2006-2007 school year, according to a survey of financial aid offices conducted by the Association of American Medical Colleges. 5 Program spending totaled about $183 million in fiscal year 2007. This number excludes funding for HRSA student loans, which utilize revolving loan funds derived generally from premium charges, and includes programs for health professionals other than medical school students and graduates, such as physician assistants and dentists. 6 Department of Veterans Affairs’ spending towards medical education in its facilities totaled about $800 million in fiscal year 2008. 7 The NRMP is affiliated with the Association of American Medical Colleges. 8 In addition to a matching service for residency programs, the NRMP also administers a matching service for fellowship programs. 9 Our review of postgraduate medical training trends focused on allopathic residency. Allopathic medicine is a system of medicine that aims to combat disease by using remedies such as drugs or surgery which produce effects that are different from or incompatible with those of the disease being treated; graduates of allopathic medical schools receive a Doctor of Medicine (MD) degree. In contrast, osteopathic medicine is a form of medical practice similar to allopathic medicine that also incorporates manual manipulation of the body as therapy; graduates of osteopathic medical schools receive a Doctor of Osteopathic Medicine (DO) degree. We excluded osteopathic residency because osteopathic residency positions make up less than 6 percent of all residency positions offered by the NRMP and the American Osteopathic Association, the organization that administers the matching service for osteopathic residency. However, osteopathic physicians are included in our review because over 35 percent of osteopathic physicians enter 1st year allopathic postgraduate medical training. 10 Our review of factors influencing specialty choice focused on medical students enrolled in U.S. medical schools leading to an MD degree. Our literature review found only limited information on the factors that influence osteopathic and international medical school students’ specialty choice and interviews we conducted with osteopathic and international medical student groups suggested that factors influencing these students may be similar to those influencing allopathic students. 11 On-call hours refer to hours when a physician can be contacted outside of regularly scheduled work hours, such as for an emergency. 12 These loans may be made by private lenders and guaranteed by the federal government or made directly by the federal government through a student’s school.

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13

HHS also noted that service obligation influences where physicians practice and the period for which they remain in their practice location. We acknowledge that specialty choice, service obligation, practice location, and duration of practice in a specific location can be interrelated, but for the purposes of this report, the issue of physician practice location and its duration were outside our scope. 14 The NHSC Scholarship Program pays for up to 4 years of support, including tuition, a monthly stipend, and other costs. 15 Oral and maxillofacial surgery programs last 4 to 6 years. 16 There is wide variation in the stipends provided to dentists in postgraduate training. Some postgraduate training programs do not provide dentists with stipends, while some may offer dentists over $47,000 annually, according to the American Dental Association (ADA). 17 Stents are small, permanent tubes placed in arteries to improve blood flow, keep arteries from narrowing or weakening, and prevent blockages. 18 Allopathic medicine is a system of medicine that aims to combat disease by using remedies such as drugs or surgery which produce effects that are different from or incompatible with those of the disease being treated; graduates of allopathic medical schools receive an MD degree. In contrast, osteopathic medicine is a form of medical practice similar to allopathic medicine that also incorporates manual manipulation of the body as therapy; graduates of osteopathic medical schools receive a doctor of osteopathic medicine (DO) degree. 19 We excluded osteopathic residency because osteopathic residency positions make up less than 6 percent of all residency positions offered by the National Resident Matching Program (NRMP) and the American Osteopathic Association, the organization that administers the matching service for osteopathic residency. In addition, we found only limited information on the factors that influence osteopathic and international medical school students’ specialty choice and interviews we conducted with osteopathic and international medical student groups suggested that factors influencing these students’ decisions may be similar to those influencing allopathic students. 20 The NRMP is affiliated with the Association of American Medical Colleges (AAMC). 21 For example, medical students can graduate from (1) a U.S. medical school leading to an MD degree, (2) a U.S. medical school leading to a DO degree, and (3) an international medical school. 22 U.S. MD students do not have to enter the NRMP match if they enter the military or Canadian matches. According to 2007 data, most physicians in U.S. postgraduate medical training earned an MD degree from a U.S. medical school. 23 There is some variation as to what specialties are included under primary care. While family medicine, general internal medicine, and general pediatrics are generally accepted as primary care specialties, other specialties that may also be considered primary care include obstetrics/gynecology, psychiatry, preventative medicine, geriatric medicine, and osteopathic general practice. 24 The GQ survey response rate declined in 2005 when the survey became optional but has since increased. 25 These data are not verified by the Department of Education (Education); therefore; they may be under or overstated. 26 Education’s repayment plan calculator is available at: http://www.ed.gov/offices/OSFAP/ DirectLoan/RepayCalc/dlentry1.html. 27 We attended its fall 2008 meeting, reviewed presentation materials, and discussed the nature of the council with HRSA, the federal agency that provides support to the council.

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Chapter 2

PHYSICIAN SUPPLY AND DEMAND: PROJECTIONS TO 2020 United States Department of Health

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BACKGROUND The United States continues to debate the adequacy of the current and future supply of physicians. While the general consensus is that overall physician supply per capita will remain relatively stable over the next 15 years, there is less agreement on future demand for physician services. This paper presents projections of physician supply and requirements for 18 physician specialties using the Physician Supply Model (PSM) and the Physician Requirements Model (PRM) developed by the Health Resources and Services Administration (HRSA). In this paper, we describe the data, assumptions and methods used to project the future supply of and requirements for physician services; we present projections from these models under alternative scenarios; and we discuss the implications of these projections for the future adequacy of physician supply. Accurate projections of physician supply and requirements help preserve a physician supply that is balanced with demand and help the Nation achieve its goal of ensuring access to high-quality, cost-effective healthcare. The length of time needed to train physicians, as well as the time needed to change the Nation’s training infrastructure, suggests that we must know at least a decade

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in advance of major shifts in physician supply or requirements. The U.S. Government Accountability Office noted in their February 2006 report "Health Professions Education Programs – Action Still Needed to Measure Impact," that regular reassessment of future health workforce supply and demand is key to setting policies as the Nation’s health care needs change. Past projections of impending physician shortages and surpluses have influenced policies and programs that, in turn, helped determine the number and specialty composition of physicians being trained. During the 1950s and 1960s, projections of a growing physician shortage helped motivate an expansion of the Nation’s medical schools, an increase in government funding for medical education, and the creation of policies and programs that encouraged immigration of foreign-trained physicians. Efforts to increase the physician supply proved so successful that, by the late 1970s, many predicted a growing oversupply of physicians (GMENAC, 1981). Rising healthcare costs paved the way for managed care and its promises to improve the efficiency of the healthcare system. Enrollment in health maintenance organizations (HMOs) during the 1980s and 1990s prompted reexamination of physician supply adequacy. The greater reliance of HMOs on the use of generalists and the prediction of decreased use of specialist services under managed care led to projections that the United States would have a large surplus of specialists (e.g., COGME, 1992, 1994; Weiner, 1994; IOM, 1996). However, the perceived limitations of the more restrictive forms of managed care prompted a public backlash against many of the forces predicted to decrease healthcare use. Also, some researchers have argued that physician projections that relied heavily on HMO staffing patterns underestimated physician requirements by failing to adequately control for out-of-plan care (Hart et al., 1997) and systematic differences in the health status of the population enrolled in HMOs and the population receiving care under a traditional fee-for-service arrangement. Cooper et al. (2002) contributed to another round of discussions regarding the adequacy of the future supply of physicians projecting a significant shortage of physicians—particularly specialists—over the foreseeable future. Other researchers have expressed concerns with the assumptions and conclusions used by Cooper et al. (Barer, 2002; Grumbach, 2002; Reinhardt, 2002; Weiner, 2002), but a growing consensus is that over the next 15 years, requirements for physician services will grow faster than supply—especially for specialist services and specialties that predominately serve the elderly. COGME joined the debate using preliminary projections from BHPr’s PSM and PRM, adjusted for COGME’s assumptions regarding the effects of key

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determinants of supply and requirements, projecting a modest shortfall of physicians by 2020. These projections helped influence the Association of American Medical Colleges (AAMC) decision to encourage growth in the Nation’s medical school training capacity by approximately 15 percent (or 3,000 physicians per year). The primary contributions of our study are (1) projections of overall physician supply and requirements to inform the debate on the Nation’s medical school capacity, and (2) specialty-specific projections of physician supply and requirements under alternative scenarios.

ACKNOWLEDGMENTS This publication was prepared for the Health Resources and Services Administration by the Lewin Group under Contract Number HRSA-230BHPr-27(2). Principal researchers were Tim Dall and Atul Grover of the Lewin Group; Charles Roehrig, Mary Bannister, Sara Eisenstein and Caroline Fulper of the Altarum Institute; and James M. Cultice of HRSA.

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Physician Supply Model BHPr’s Physician Supply Model produces national projections of physician supply for 36 medical specialties through 2020, which are aggregated into 18 specialties for comparison to the PRM projections. The PSM is an inventory model that tracks the supply of physicians by age, sex, country of medical education (whether United States medical graduates [USMG] or international medical graduates [IMG]), type of degree (i.e., Medical Doctor [MD] or Doctor of Osteopathy [DO]),1 medical specialty, and primary activity (e.g., patient care or non-patient care). The PSM (Exhibit 1) projects the future supply of physicians based on: Number of physicians in the preceding year (starting with the base year 2000), Number of new USMGs and IMGs, and Attrition due to retirement, death and disability.

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United States Department of Health

.

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Exhibit 1. Overview of the Physician Supply Model

The PSM produces two measures of physician supply: (1) the number of active physicians and (2) the number of full-time equivalent (FTE) physicians. One FTE is defined as the average annual hours worked in patient care per physician in 2000, and these estimates vary by specialty. Women and older physicians historically have worked fewer patient care hours, on average, compared to male and younger physicians, and because a growing proportion of the physician workforce is female and older the FTE supply of physicians is growing slightly slower than the number of active physicians. Below, we describe the major components of the PSM and our findings.

Current Physician Workforce The starting point for projecting physician supply is estimating the size and characteristics of the current physician workforce. The primary sources for this information are the American Medical Association (AMA) and the American Osteopathic Association (AOA). As of the base year (2000), an estimated 756,0002 active physicians under age 75 were practicing in the United States. Approximately 95 percent are MDs and 5 percent are DOs. PSM projections suggest that the current number of active physicians under age 75 (as of 2005) is approximately 817,500. Slightly over one third are generalists (family practice, general pediatrics or general internal medicine); the remaining two thirds are specialists (Exhibit 2). Physician demographics have important supply implications. Physician age is correlated with retirement probability and annual hours worked, and a growing proportion of physicians are nearing historical retirement age as illustrated by the shifting physician age distribution (Exhibit 3).

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Currently, one in four physicians is female, but two factors are contributing to a rise in female representation. First, during the past three decades the proportion of new medical graduates who are female has risen from 10 percent to close to 50 percent. Second, the growth in female representation is a relatively recent phenomenon, and it is predominantly male physicians who are nearing retirement age. Although one in three active male physicians is age 55 or older, only one in eight active female physicians is age 55 or older.

Source: Projections from the BHPr Physician Supply Model.

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Exhibit 2. Estimates of Primary Specialty of Active Physicians, 2005

Source: Physician Supply Model. Exhibit 3. Age Distribution of Physician Workforce under Age 75, 2000 to 2020

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Because work and retirement patterns differ systematically for male and female physicians, the increasing proportion of physicians who are female has profound implications for the overall supply of physician services. Female physicians are more likely than their male counterparts to choose non-surgical specialties and to spend fewer hours per year providing patient care. They are also less likely to work in rural areas, and they tend to retire slightly earlier. The PSM also tracks primary activity (patient care or other). An estimated 94 percent of active physicians are engaged primarily in patient care activities, while the remaining 6 percent are engaged primarily in non-patient care activities such as administration, teaching, research, and others.

New Entrants and Choice of Medical Specialty Almost 24,000 physicians complete their training through programs of graduate medical education (GME) each year. Before completing residencies and fellowships, new physicians must earn a four-year college degree and complete four years of medical education. Four out of five physicians completing GME are graduates of United States medical schools. Most are graduates of schools of allopathic medicine, which annually graduate approximately 15,000 to 16,000 MDs. This number has been relatively stable since 1980, and the baseline projections assume that the U.S. will continue to graduate approximately 16,000 MDs per year through 2020. Schools of osteopathic medicine graduate approximately 3,000 DOs per year, and the baseline supply projections assume that this number will steadily increase to approximately 4,000 per year over the next decade. Over 5,000 IMGs are accepted into United States GME programs each year. An increasing percentage of IMGs are citizens or permanent residents (US IMG) who graduated from medical schools in other countries. Foreign IMGs under enter the United States for GME under the temporary work (H) or training (J) visa programs. Foreign IMGs with a J visa can participate in the J-1 Visa Waiver Program, which allows physicians to remain in the United States, if they agree to provide primary care services in federally-designated health professional shortage areas (HPSAs) for a minimum of three years after completing their residency. The PSM projects the number of IMGs who will remain in the United States based on historical patterns that vary by specialty. The PSM models specialty choice based on the number of medical graduates entering different GME residency programs, historical trends of specialization as estimated through an analysis of the AMA Masterfile data, and data from the AAMC medical school Graduation Questionnaire. A more complete description of the specialty allocation is provided in other reports

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(e.g., Altarum, 2000). Specialty choice varies substantially by gender and by whether students are USMGs or IMGs. Among USMGs, for example, female physicians are three times more likely to become pediatricians than are male physicians.

Separations from the Physician Workforce Physicians leave the workforce through retirement, mortality, disability, and career change. An accurate estimate of separation rates is crucial for projecting physician supply when a large number of physicians are approaching retirement. The PSM combines estimates of physician retirement rates with mortality rates for college educated men and women in the United States obtained from the Centers for Disease Control and Prevention (CDC) to estimate the probability that a physician of a given age and sex will remain active in the workforce from year to year. Concerns that the current AMA Masterfile overstates the likelihood that older physicians are still active prompted consideration of two alternative sources of retirement rates: the Physician Worklife Survey (PWS)3 and the Current Population Survey (CPS)4. Retirement rates estimated with AMA Masterfile data from the early to mid 1990s were found to be relatively consistent with rates estimated with PWS and CPS data. We use the AMAbased retirement rates in the PSM (Exhibit 4). We obtained much lower retirement rates when using more recent data from AMA, and concluded that the process AMA currently uses to update its records results in a lag between when a physician’s activity status changes and when that change is recorded in the AMA Masterfile. Furthermore, activity status is self reported, and some retired physicians might fail to respond to the AMA survey. Recognizing this problem, the AMA automatically recodes as retired all physicians age 75 and older who fail to respond to its survey and all physicians who receive AMA retirement benefits. For our projections, we assume that that all physicians retire by age 75. The data suggest that physicians continue working to an older age than do people in other professions. Other analyses not presented here find that female physicians retire slightly earlier than do male physicians. Anecdotal evidence and economic theory suggest that retirement patterns will fluctuate due to changes in economic factors and physicians’ overall satisfaction with the healthcare operating environment. For example, recent declines in the wealth of physicians due to adverse economic conditions and a decline in practice valuation might delay retirement plans for some physicians. For modeling purposes, we focus on long-term trends that affect retirement

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patterns (e.g., the increasing number of women in the physician workforce) rather than factors that cause short-term fluctuations in retirement patterns.

Trends in Physician Productivity Trends in physician productivity are important to consider when projecting supply of physician services. If physicians are more (or less) productive in future years, then more (or less) services can be provided with any given number of active physicians. Measures of physician productivity in the literature include the following:

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Hours spent providing patient care. Projected changes over time in average hours worked are incorporated into the PSM. Our analysis of AMA’s 1998 Socioeconomic Monitoring System (SMS) file finds that female physicians tend to work approximately 15 percent less time in patient care than do their male counterparts after controlling for age, specialty, and IMG status. Physicians over age 65 and under age 36 work fewer hours per year than their middle-aged colleagues, and over time average hours in direct patient care for these two groups has been declining (Exhibit 5). Part of the decline for the younger group reflects a growing proportion of women in the workforce.

Exhibit 4. Percent of Physicians Active in the Workforce, by Physician Age

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Number of patients seen. Changes in the use of non-physician clinicians (NPC) and other health workers, technological advances, epidemiological trends, amount of time spent with patients per visit, and changes in the healthcare operating environment could all affect the average number of patients seen per physician during a given period of time. AMA publications show that the average number of patient visits declined during the 1990s (Exhibit 6) due mainly to a decline in hospital round visits (Exhibit 7), with office visits per physician remaining relatively constant (Exhibit 8). Unfortunately, these statistics are no longer collected by AMA. Resource-Based Relative Value Scale. A set of codes developed by the Center for Medicare and Medicaid Services (CMS), the ResourceBased Relative Value Scale (RBRVS), helps determine the Medicare fee schedule. (Many private insurers also use a form of the RBRVS). The RBRVS has three cost components, one of which is the Relative Value Unit (RVU) that measures physician work as a function of both the time and skill necessary to provide a particular service. More complex and time consuming services have higher RVUs. Data from the Medical Group Management Association (MGMA) cost survey suggest that between 1998 and 2002 the median annual work RVUs per physician were either constant or possibly increasing slightly (Exhibit 9). For example, during this period median work RVUs per physician in multi-specialty practices increased from 5,368 to 5,489 (about 0.6 percent per year). For multi-specialty, hospital-owned practices, the annual growth rate over this four-year period was approximately 7 percent, while for practices not owned by hospitals, the annual growth rate was approximately -0.5 percent. The number of support staff per FTE physician has also increased (Exhibit 10). Between 1996 and 2002, the number of support staff per FTE physician in multi-specialty practices increased 1.4 percent annually. The annual growth rate for family practice groups over this six-year period was 1.2 percent. To capture these trends in greater physician productivity, for our sensitivity analysis, we project a physician supply scenario under the assumption that productivity will increase by 1 percent annually.5

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Source: AMA Physician Socioeconomic Statistics, various years; 2002 estimates from BHPr.

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Exhibit 5. Trends in Annual Hours Worked

Source: AMA Physician Socioeconomic Statistics, various years. Exhibit 6. Average Total Visits per Week

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Physician Supply and Demand: Projections to 2020

Source: AMA Physician Socioeconomic Statistics, various years.

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Exhibit 7. Average Hospital Round Visits per Week

Source: AMA Physician Socioeconomic Statistics, various years. Exhibit 8. Average Office Visits per Week

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Source: MGMA Cost Survey, various years.

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Exhibit 9. Physician Work RVUs per FTE Physician

Source: MGMA Cost Survey, various years. Exhibit 10. Total Support Staff per FTE Physician

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Physician Supply Projections The baseline projections of physician supply assume that current patterns of new graduates, specialty choice, and practice behavior continue.6 The number of active physicians under the age of 75 grew from approximately 756,000 in 2000 to an estimated 817,500 in 2005, and this number is projected to grow to approximately 951,700 by 2020 if current trends continue (Exhibit 11). FTE supply projections provide a more accurate picture of the adequacy of supply (than do projections of active physicians) because the FTE projections consider the decrease in average hours worked as the physician workforce ages and women constitute a growing proportion of physicians.7 The estimated number of physicians in clinical practice (which excludes residents and physicians primarily in non-patient care activities, increases from approximately 635,800 in 2005 to 719,800 by 2020 (Exhibit 12). FTE supply of physicians engaged primarily in patient care activities (including residents) grew from approximately 714,000 in 2000 to approximately 764,000 by 2005 (Exhibits 13, 14, and 15). Although total physicians engaged primarily in patient care grew by approximately 56,000 between 2000 and 2005, the estimated decrease in average hours worked suggests that during this period the net increase in total patient care hours was equivalent to only 50,000 physicians. By 2020, FTE physicians engaged primarily in patient care is projected to reach 866,000 (a 10 percent increase from current levels). The projected growth in supply varies substantially by medical specialty, reflecting differences in the components of supply (e.g., number of new entrants, age distribution) for each specialty. If current supply trends continue, the number of FTE primary care physicians engaged primarily in patient care is projected to grow approximately 18 percent between 2005 and 2020, compared to a growth rate of 10 percent for non-primary care physicians. FTE supply in some surgical specialties is projected to decline. Reflecting the dynamic nature of physician supply, an increasing percentage of first-year residency positions in general surgery have been filled in recent years; over 95 percent of these positions were filled in 2005 (AAMC, 2005). Thus, these supply projections likely overestimate the size of projected shortages and surpluses within individual specialties because the Nation can adjust more quickly to inadequacies in the supply of individual specialties than to inadequacies in the overall supply of physicians. The United States Census Bureau’s middle series population projections suggest that the United States population will grow by approximately 14 percent between 2005 and 2020, approximately the same rate as FTE

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physician supply, resulting in a relatively constant FTE patient care physician per 100,000 population ratio of approximately 259 (Exhibits 16 and 17).

*

Includes total active MDs and DOs. Physicians age 75 and older are excluded. Note: Totals might not equal sum of subtotals due to rounding. Exhibit 11. Supply of Total Active Physicians*: 2000, Projected to 2020

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*

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Includes MD and DO office-based and hospital staff physicians. Excludes residents, and those in nonpatient care. Physicians age 75 and older are excluded. Note: Totals might not equal sum of subtotals due to rounding. Exhibit 12. FTE Supply of physicians in clinical practice*: 2000, Projected to 2020

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*

Includes MDs and DOs. Residents are not FTE-adjusted. Specialties are grouped to agree with those groupings shown in the projected requirements tables, Exhibits 30 and 32. Physicians age 75 and older are excluded. Note: Totals might not equal sum of subtotals due to rounding. Specialties are aggregated to be comparable to the specialty categories from the Physician Requirements Model (see Exhibit 30). Exhibit 13. FTE Supply of physicians in clinical practice, and residents*: 2000, Projected to 2020

Total active, patient care physicians are projected to increase to 891,000 by 2020, but the number of FTE physicians is projected to increase to only 866,000 (Exhibit 18). Under the assumption that physician productivity increases by 1 percent annually (e.g., through improved training, technological advances, and increased use of other health professionals), by 2020 the actual physician supply would be equivalent to approximately 1,057,000 physicians (in comparison to year 2000 physicians). The PSM can also be used to project supply under alternative United States medical school output scenarios. As shown in Exhibit 19, if medical schools could instantaneously increase the number of graduates by 10 to 20

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percent, the impact on physician supply by 2020 would be approximately 30,000 to 60,000 additional physicians.

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Exhibit 14. Baseline FTE Physician Supply Projections

Exhibit 15. Percentage Growth in FTE Physician Supply

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Exhibit 16. FTE Physicians per 100,000 Population

Exhibit 17. Percentage Growth in FTE Physicians per Capita

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Exhibit 18. Alternative Patient Care Supply Projections

Exhibit 19. Increased Output from U.S. Medical Schools

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While the future national supply of physicians is relatively straightforward to project in the aggregate, projections by medical specialty are more difficult to calculate because a large number of factors influence specialty choice. Furthermore, the number of medical school graduates has been relatively constant over the past two decades while the number of physicians choosing a particular specialty can vary substantially from year to year. If specialty choice trends from the late 1990s and early 2000s continue, the number of FTE physicians in primary care specialties will grow approximately 18 percent between 2005 and 2020, compared to a growth rate of 10 percent for non-primary care physicians. There appears to have been a swing back towards specialization in the past few years, reflecting the dynamic nature of specialty choice. The PSM attempts to capture the major trends affecting physician supply but is a relatively simple representation of the millions of supply-related decisions physicians and the institutions make that affect physician training and practice. Like all projection models, the accuracy of the projections diminishes with the time horizon such that short-term projections are likely more accurate than longer-term projections. Similarly, projections for broader categories of medical specialties are likely more accurate than projections for narrowly defined medical specialties. Furthermore, many physician specialties have overlapping scopes of practice that blur the distinction between individual related specialties.

Physician Requirements Model The PRM uses a utilization-based approach to estimate physician requirements.8 The PRM projects requirements for 18 medical specialties through 2020 based on current use patterns of physician services and expected trends in United States demographics, insurance coverage, and patterns of care delivery. These use patterns are expressed as physician-to-population ratios for each specialty and population segment defined by age, sex, metropolitan/nonmetropolitan location, and insurance type. The baseline ratios are established using 2000 data. Thus, the three major components of the model are: (1) Population projections by age,9 sex, and metropolitan/nonmetropolitan location; (2) Projected insurance distribution by insurance type, age, sex, metropolitan/non-metropolitan location; and

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(3) Detailed physician-to-population ratios (Exhibit 20).

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Below, we explore trends in major determinants of physician requirements as well as potential impact of alternative assumptions regarding these trends.

Growth and Aging of the Population The United States Census Bureau projects a rapid increase in the elderly population beginning in 2012 when the leading edge of the baby boom generation approaches age 65 (Exhibit 21). Between 2005 and 2020, the population younger than age 65 is expected to grow by about 9 percent, while the population age 65 and older is projected to grow by about 50 percent. The elderly use much greater levels of physician services relative to the non-elderly, so the rapid growth of the elderly population portends a significant increase in demand for physician services. To estimate differences in use of physician services by different demographic groups, for each physician specialty we estimated per capita encounters for segments of the United States population categorized by age, sex, and insurance status (BHPr, 2003). After determining what portion of physicians’ time is spent with each segment of the population, we calculated physician-per-population ratios that reflect current use patterns and current patterns of care. For presentation purposes, these ratios are summarized in estimates of physician requirements per 100,000 population for four categories of physicians and six age groups (Exhibit 22). In 2000, for the United States population as a whole, approximately 253 active physicians (MDs and DOs) were engaged primarily in patient care per 100,000 population.10 The aggregate estimates ranged from a low of 149 for the population ages 0 to 17, to a high of 781 for the population ages 75 and older. The ratios vary substantially by medical specialty. These data suggest that the aging of the population will contribute to faster growth, in percentage terms, for specialist services relative to the growth in demand for primary care services.

Exhibit 20. Overview of the Physician Demand Model

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Source: United States Census Bureau population projections (April 2005 release).

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Exhibit 21. Population Growth, 2000 to 2020

Source: PRM. 1 Includes general and family practice, general internal medicine, and pediatrics. 2 Includes cardiology and other internal medicine subspecialties. 3 Includes general surgery, obstetrics/gynecology, ophthalmology, orthopedic surgery, otolaryngology, urology and other surgical specialties. 4 Includes anesthesiology, emergency medicine, pathology, psychiatry, radiology, and other specialties. Exhibit 22. Estimated Requirements for Patient Care Physicians per 100,000 Population, by Patient Age and Physician Specialty, 2000.

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Medical Insurance Trends Insurance status and type are important determinants of use patterns. Insurance greatly reduces the marginal cost of obtaining physician services, and cost sharing (deductibles, coinsurance) and plan restrictiveness (managed indemnity versus closed network HMOs) can affect access to certain physician specialties and practice settings. The PRM divides the United States population into four mutually exclusive insurance groups:11

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(1) Insured under a fee-for-service arrangement; (2) Insured in an exclusive network HMO (e.g., group-, staff-, network-, or mixed-model HMO); (3) Insured under a different type of managed care plan (e.g., preferred provider organization [PPO], point of service [POS] organized as open-ended HMO, non-HMO POS, and other HMO/managed care plans); and (4) Uninsured.

Exhibit 23. Per Capita Use of Physician Services (as a percentage of per capita use under an insured, fee-for-service arrangement).

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In the baseline scenario, we assume a constant insurance probability for each population group defined by age and sex using the year 2000 insurance distribution. Based on use patterns determined through an analysis of the NIS, NHAMCS, NAMCS, NNHS and other sources, we estimated how per capita use of physician services compares under these four insurance types after controlling for population age and sex (Exhibit 23). For example, individuals in an exclusive network HMO use 86 percent as many anesthesiology services as individuals in a plan modeled after a traditional fee-for-service arrangement (controlling for age and sex). Individuals insured under other types of managed care plans and uninsured individuals use 98 percent and 29 percent as many anesthesiologist services, respectively, as individuals insured under the fee-for-service type plan.

Economic Factors Recently, Cooper et al. (2002) started another round of discussions regarding the adequacy of the future supply of physicians arguing that economic growth is the major determinant of growth in per capita demand for physician services and that continued economic growth will contribute to a significant shortage of physicians—and in particular specialists—over the next decade. Historically, economic growth per se has not been a component of the PRM, although the PRM models trends in insurance patterns that arguably capture some of the historical relationship between economic growth and demand for healthcare services. Below, we consider some arguments for and against including economic growth as a determinant of demand in the PRM. Reasons why economic growth might increase physician requirements Theory. Like most goods and services, healthcare is considered a “normal” good where individuals consume larger amounts as their ability to pay rises. At the household level, increased income allows individuals greater opportunities to obtain medical insurance and afford copays and deductibles. At the national level, economic growth allows governments and employers to expand and provide more generous medical insurance coverage. Empirical correlation. Time series and cross-sectional analyses using States and countries12 as the unit of analysis find a positive correlation between the number of physicians per capita (a supply

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measure used as a proxy for demand) and economic wellbeing (measured as income per capita or GDP per capita). Cooper et al. operate on the assumption that historical rates of physicians per capita reflect per capita demand for physician services and estimate the relationship between physicians per capita and GDP per capita using annual data from 1929 to 2000. The authors conclude that each 10 percent increase in GDP per capita results in a 7.5 percent increase in demand for physician services (i.e., an income elasticity of 0.75). This income elasticity estimate is similar to that obtained by Cookson and Reilly (1994) and Koenig et al. (2003); however, all of these studies faced significant data limitations. Other researchers have questioned Cooper et al.’s approach, assumptions, and conclusions (e.g., Barer, 2002; Grumbach, 2002; Reinhardt, 2002; Weiner, 2002).

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We conducted preliminary analyses using cross-sectional data for States and countries and found income elasticity estimates approximately half the size of Cooper et al.’s estimates. This finding is consistent with an income elasticity estimate of 0.31 by Koenig et al. (2003) when they examined the relationship between income per capita and expenditures for physician services. The standard errors of our estimates are large, however.

Reasons why economic growth might fail to increase physician requirements: Increased productivity. Real per capita economic growth occurs through increased productivity. If physicians become more productive over time, their increased productivity will partially offset any increase in demand for physician services due to economic growth. If, for example, as Cooper et al. estimate, the income elasticity of demand for physician services is 0.75, then an increase in physician productivity that is at least 75 percent of the national average increase in productivity would exactly offset any effect of economic growth on demand for services, thus resulting in no change in physician requirements per capita. Improved health. Economic growth allows individuals and communities to live healthier lives. Examples include improved diet, improved access to preventive medicine, and increased support for

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United States Department of Health public health initiatives that might, in turn, reduce physician requirements. Counter-cyclical insurance patterns. One explanation for a positive, causal correlation between economic wellbeing and physician requirements is that economic growth allows governments and employers to expand insurance coverage. Holahan and Pohl (2002) find, however, that changes in GDP per capita in the United States during the period 1994 to 2000 results in little change in the overall number of insured persons. Although downturns in economic activity result in a decline in number of persons insured under private plans, economic downturns result in an increased number of households eligible for Medicaid.

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The relationship between economic wellbeing and healthcare utilization is likely non-linear, with the correlation becoming weaker at higher income levels as a saturation point is reached. That individuals with greater income will respond by purchasing more routine physician services if they are already well insured is unlikely. Thus, any relationship between economic wellbeing and demand for physician services is likely to be stronger for specialist services than for primary care services. In summary, additional empirical research is required to estimate the longterm relationship between economic growth and physician requirements. This issue also raises numerous political questions regarding whether projections of the adequacy of physician supply should incorporate patients’ increased appetite for a more expansive healthcare system as the Nation becomes wealthier. For comparison, we project future requirements using Cooper et al.’s assumption of a 0.75 elasticity and the assumption of annual 2 percent growth in real per capita GDP based on Congressional Budget Office (CBO) projections.

Other Potential Determinants of Demand for Physician Services One of the challenges in projecting physician requirements is that changes in technology, the use of non-physician clinicians (NPCs) and other health workers, public expectations, and government policies all can alter use patterns and the way care is delivered. Because of uncertainties regarding what new developments might occur and their impact on demand for physician services, the baseline projections assume constant physician per population

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ratios over the two decades of projections. Below, we describe trends that could affect physician requirements.

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Technological advances. Technological advances continue to change the way in which healthcare services are delivered. Some new technologies create immediate additional demand for physician services (e.g., advances in fertility technology); other advances hold the potential to prevent costly medical conditions (e.g., gene therapy), thus immediately reducing the demand for selected services. Predicting how such advances will change the long-run demand for physician services is difficult. For instance, new techniques in invasive cardiology might help prevent costly surgeries and their comorbidities, but the added years of life gained from such procedures might translate into greater use of services over an individual’s lifetime. Similarly, telemedicine has the potential to reduce access barriers thus increasing demand for physician services. Non-Physician Clinicians. The NPC workforce continues to grow as does the proportion of healthcare services NPCs provide (Cooper, Laud, and Dietrich, 1998; Druss et al., 2003). Although NPCs sometimes compete with physicians, they also complement physicians by providing services within the scope of their training with physicians directing overall care and handling the more complex cases. Increased use of NPCs allows physicians to become more productive (e.g., in terms of seeing more patients), which increases the supply of physician services but also means we need fewer physicians to provide care to a given population. Public expectations. Public expectations of medicine are different today than they were 100 years ago, or even 20 years ago. New medicines have improved the ability to care for chronic conditions, and others have improved quality of life for many individuals. The Institute of Medicine (IOM) has highlighted the prevalence of medical errors, leading to increased scrutiny of quality of care by the public and by policymakers. The elderly baby boom population will have experienced different hardships than their grandparents, which might also affect their expectations of the healthcare system. Physician specialties involved in both acute and long-term care of the elderly will be affected.

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United States Department of Health Policy changes. The changing role of government, which is closely linked to public expectations, might also exert a significant impact on demand for physician services (e.g., through the impact of regulation as well as payment policies).

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Physician Requirements Projections The baseline projections suggest that between 2005 and 2020 overall requirements for physicians engaged primarily in patient care increase 22 percent, from approximately 713,800 to 921,500 (Exhibits 24, 26, and 27). In percentage terms, growth is lower for primary care (20 percent) than for nonprimary care (23 percent). If we assume that requirements for physicians engaged primarily in non-patient care activities (e.g., administration, teaching, and research) remain relatively constant at approximately 6 percent of total physicians, then total requirements for physicians will increase from about 756,100 to 976,000 during this period.13

*

Base year assumes that physician supply and demand are balanced.

Exhibit 24. Baseline Projections of Physician Requirements

*

Base year assumes that physician supply and demand are balanced.

Exhibit 25. Baseline Physician Requirements per 100,000 Population.

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Exhibit 26. Patient Care Physician Requirements

Exhibit 27. Percentage Growth in Patient Care Physician Requirements

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Exhibit 28. Patient Care Requirements per 100,000 Population

Exhibit 29. Percentage Growth in Patient Care Requirements per Capita

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Note: Due to rounding, sum of subtotals may not equal totals. Exhibit 30. Physician Requirements by Medical Specialty: Baseline Projections.

On a per capita basis, demand for physicians is increasing as a result of an aging population (Exhibits 25, 28, and 29). For example, under the baseline scenario, requirements for physicians engaged in patient care increases from approximately 259 to 281 (8 percent) per 100,000 population between 2005 and 2020. In percentage terms, the increase is greater for non-primary care (9 percent) than for primary care (7 percent). Projected growth in requirements between 2005 and 2020 varies substantially by specialty (Exhibit 30). Between 2005 and 2020, specialties with the highest percentage growth are cardiology (33 percent) and urology (30 percent). Specialties with the lowest percentage growth are pediatrics (9 percent) and obstetrics/gynecology (10 percent). The baseline projections assume that patterns of healthcare use and delivery of care remain unchanged over the projection horizon and that changing demographics are the primary driver of changes in physician

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requirements. To better understand the implications of possible changes in utilization and delivery patterns we project physician requirements from 2005 to 2020 under alternative scenarios (Exhibits 31 and 32).

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Growing role of NPCs. This scenario assumes that (1) the number of active NPCs will increase 60 percent between 2005 and 2020; (2) all NPCs that are trained will become employed and will provide services that otherwise would have been provided by physicians; and (3) on average each NPC will provide 40 percent of the work currently provided by a physician. Under this scenario, by 2020 physician requirements would be approximately 90,000 physicians less than the baseline projections. NPCs will have a disproportionate impact by specialty, with NPCs having a greater impact on reducing demand for generalists. ] Economic growth. This scenario assumes that economic growth will allow the Nation to afford a higher-quality healthcare system. This new healthcare system will require more physicians and, in particular, more specialists. Physician requirements are projected under the assumption that per capita income will grow by 2 percent annually, and that demand for some specialties is relatively insensitive (elasticity=0.25)14, modestly sensitive (elasticity=0.50)15, or more sensitive (elasticity=0.75)16 to economic growth. The latter scenario produces the highest projections, with requirements growing to 1.1 million physicians in 2020 (136,000 higher than the baseline projection). Projections by specialty are provided in Exhibit 32. Physician productivity increase. Requirements are projected under the assumption that physician productivity will increase 1 percent per year (i.e., each physician can see 1 percent more patients per year through improved use of staff and technology). Projected physician requirements remain relatively constant through 2020 under this scenario, with the projection suggesting 137,000 fewer physicians than projected under the baseline scenario in 2020. Economic growth offset by physician productivity increase. Combining the previous two scenarios, the growth in demand for physician services due to economic growth is offset by the increased

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productivity of physicians resulting in projected requirements of 956,000 in 2020 (20,000 fewer than under the baseline scenario).

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Assessing the Adequacy of Current and Future Supply The PRM uses current patterns of healthcare use and delivery of care to project future demand for physician services. This utilization-based approach relies on the assumption that healthcare utilization and service delivery patterns in the base year (2000) are ―adequate.‖ That is, the PRM relies on the implicit assumption that physician supply is in balance with physician requirements in the base year at the national level. Inefficiencies in the market resulting from current oversupply or undersupply of physicians are extrapolated into the future. The baseline projections suggest that if current trends continue, overall primary care physician supply and requirements will grow at about the same rate over the next 15 years at which time requirements will grow faster than supply (Exhibit 33). These national projections mask the geographic variation in adequacy of supply. HRSA estimates that approximately 7,000 additional primary care physicians are currently needed in underserved areas to dedesignate federally-designated shortage areas.

Exhibit 31. Alternative Requirements Projections.

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Note: Due to rounding, sum of subtotals may not equal totals. Exhibit 32. Physician Requirements by Medical Specialty: High Economic Growth Series.

Because the national supply of primary care physicians is growing at roughly the same rate as requirements, there will likely be little change in market pressures to improve the undersupply of primary care physicians in rural and other underserved communities. Under the high-demand growth scenario, growth in demand for primary care physicians exceeds growth in supply. Between 2005 and 2020, demand for non-primary care physicians will grow faster than supply (Exhibit 34). These national projections mask the projected inadequacies in individual specialties, with specialties such as general surgery, urology, ophthalmology,

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cardiology, pathology, orthopedic surgery, other internal medicine subspecialties, otolaryngology, radiology, and psychiatry seeing demand grow much faster than supply.

Exhibit 33. Growth in Primary Care Supply and Demand

Exhibit 34. Growth in non-Primary Care Supply and Demand

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SUMMARY The growth and aging of the United States population will cause a surge in demand for physician services. If current healthcare utilization and delivery patterns continue, the overall supply of physicians should be sufficient to meet the expected demand through the next 10 years. This finding suggests the need for modest increases in United States medical school capacity. Currently, one in four physicians in a residency programs graduated from a foreign medical school, and a large portion of IMGs remain in the United States after completing their graduate training. If the United States desires to rely less on IMGs to meet the growing demand for physician services, then United States medical school capacity must be expanded beyond the expansion necessary to meet the needs of a growing and aging population. The baseline projections suggest the possibility of future realignments in graduate medical training, expanding the number of physicians trained in some specialties (e.g., general surgery, urology, ophthalmology, cardiology, pathology, orthopedic surgery, other internal medicine subspecialties, otolaryngology, radiology, and psychiatry). Models to project physician supply and demand are often sensitive to assumptions regarding the characteristics of the future healthcare system and whether current trends will persist. Replete with examples of projected trends that failed to fully materialize and the emergence of trends that were never anticipated, the history of the United States healthcare system shows a system that is continually evolving. As Uwe Reinhardt (2002, p. 196) states: it is a ―daunting enterprise . . . to estimate the physician surplus or shortage one or two decades into the future. Any of the variables in the equation can change over time, sometimes in unforeseen ways.‖ This fact is especially true when projecting demand for physician services, where much uncertainty exists regarding the characteristics of the future healthcare system. [It is a] “daunting enterprise . . . to estimate the physician surplus or shortage one or two decades into the future. Any of the variables in the equation can change over time, sometimes in unforeseen ways.” Uwe Reinhardt (2002)

Factors leading to potential underestimates of physician requirements include: (1) underestimates by the United States Census Bureau of actual population growth, (2) overestimates of the proportion of population insured through plans with aggressive managed care practices, (3) overestimates of

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proportion of care provided by NPCs, (4) underestimates of increased per capita use of physician services over time, and (5) overestimates of increases in physician productivity. Although we are unable to predict with certainty whether current trends in the healthcare operating environment will persist and what new trends will emerge, efforts to model physician supply and demand require educated predictions of major trends that affect the physician workforce. These uncertainties, combined with an ever changing healthcare system, highlight the need to frequently reassess supply and requirements projections. In addition to the uncertainties mentioned above that affect the accuracy of projections, the PSM and PRM, like all projections models, have their limitations. For example, both models are static in that they do not model how physicians, patients, and insurers will react to changing conditions. As an example, physician earnings tend to increase as demand exceeds supply, resulting in financial incentives for physicians to enter specialties with a shortage of physicians rather than entering specialties with a surplus of physicians. Similarly, the scope of practice in particular specialties is changing over time. An expanded scope of practice could result in greater physician requirements for that specialty, with the possibility that requirements might fall for a specialty with an overlapping scope of practice that competes for many of the same patients. A limitation of a utilization-based approach to model physician requirements is that, by definition, the approach assumes that the physician labor market is in balance in the base year. Inefficiencies in the delivery of care are extrapolated into future years’ projections. Another limitation is that the PSM and PRM are national models. Although they can be adapted to project supply and demand for smaller geographic regions such as States, the models do little to inform the debate regarding the future adequacy of physician supply in currently underserved areas. Past government policies to improve physician supply in underserved areas have relied in part on the assumption that physician surpluses (especially surpluses of primary care physicians) will create financial motivations for physicians to gravitate to underserved areas. The baseline projections suggest that the supply of primary care physicians will grow at about the same rate as demand through 2020, which will create little financial pressure for primary care physicians to disperse to traditionally underserved areas. Additional research that might improve the supply projections include the following:

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United States Department of Health Estimating more exact retirement patterns. As discussed, the PSM uses historical data to estimate separation rates that we think reflect long-term trends, rather than short-term fluctuations reflecting current market conditions. Preliminary results from the PWS are consistent with the concern that AMA Masterfile data underestimate the number of retired physicians, which could lead to overestimates of physician supply.

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Modeling specialty choice. The PSM uses historical data to estimate the distribution of new physicians into various specialties. This reliance on historical data might understate the importance of new trends in specialty choice—especially as it pertains to relatively new specialties such as critical care. Estimating long-term trends in physician productivity. With the exception of modeling trends in average hours worked as women and older physicians constitute a growing portion of the physician workforce, the PSM does not explicitly model changes in physician productivity. We calculated the productivity scenario presented in this paper outside the model and assumed a 1 percent annual increase in physician productivity. Improved training, technological advances, and increased use of NPCs and other health workers could lead to increased productivity, and additional research could inform how such productivity increases should be incorporated into the physician supply projections. Additional research that might improve the demand projections includes the following: Estimating the impact of economic growth on physician requirements. Economic growth could change patient expectations and the ability of patients, employers, and the government to purchase additional physician services. The recent work by Cooper et al. has opened the debate on this topic, but the research community is far from reaching a consensus on the implications of economic growth for the future adequacy of physician supply. Estimating the impact of growing NPC supply on physician requirements. Expansion of the clinical or business autonomy of

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NPCs could increase competition between NPCs and certain physician specialties, resulting in slower growth in physician requirements. Similarly, collaboration between NPCs and supervising physicians can increase physician productivity, which in turn reduces physician requirements. Estimating the impact of new technologies on short-term and long-term requirements for physicians. New technologies could allow physicians to provide new services, and they could reduce mortality, increasing long-term requirements. Likewise, new tests, procedures, pharmaceuticals, or equipment could provide a substitute for some physician services thus slowing the growth in physician requirements.

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Despite the limitations of projection models like the PSM and PRM, and despite the uncertainties of how the healthcare system will look in the future, these two models are powerful tools for understanding the implications of changing demographics, changing government policies, and other trends on the future adequacy of physician supply.

REFERENCES Altarum. (2000). Report of Work Performed on the Physician Supply Model. Report by Altarum Institute (formerly Vector Research Incorporated) to the National Center for Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration. American Medical Association. Physician Characteristics and Distribution in the United States Various years. American Medical Association. Physician Socioeconomic Statistics. Various years. American Osteopathic Association. Statistical Fact Sheet. Various years. Barer, M. (2002). New opportunities for old mistakes. Health Affairs, 21(1), 169–171. Bureau of Health Professions. (2003). Changing Demographics and the Implications for Physicians, Nurses, and Other Health Workers. Lewin Group report prepared for the Bureau of Health Professions, Health Resources and Services Administration. Available at

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. Accessed December 2005. Bureau of Health Professions. (2006). The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. Lewin Group report prepared for the Bureau of Health Professions, Health Resources and Services Administration. Brotherton, S.E., Simon, F.A. & Tomany, S.C. (2000). United States graduate medical education, 1999–2000. JAMA, 284, 1121–1126. Chernew, M. E., Hirth, R. A. & Cutler, D. M. (2003). Increased spending on health care: How much can the United States afford? Health Affairs., 22(5), 15-25. Cookson, J. P. & Reilly, P. (1994). Modeling and Forecasting Healthcare Consumption. Cooper, R. A. (2002). There’s a shortage of specialists: Is anyone listening? Acad Med., 77, 761-766. Cooper, R. A., Laud, P. & Dietrich, C. L. (1998). Current and projected workforce of nonphysician clinicians. JAMA, 280, 788-794. Cooper, R. A., Getzen, T. E., McKee, H. J. & Laud, P. (2002). Economic and demographic trends signal an impending physician shortage. Health Affairs, 21(1), 140-154. Council on Graduate Medical Education. (1992). Improving Access to Health Care through Physician Workforce Reform: Directions for the 21st Century. Third Report. Rockville, MD: United States Department of Health and Human Services. Council on Graduate Medical Education. (1994). Recommendation to Improve Access to Health Care through Physician Workforce Reform. Fourth Report. Rockville, MD: United States Department of Health and Human Services. Council on Graduate Medical Education. (1995). Managed Health Care: Implications for the Physician Workforce and Medical Education. Sixth Report. Rockville, MD: United States Department of Health and Human Services. Council on Graduate Medical Education. (1996). Patient Care Physician Supply and Requirements: Testing COGME Recommendations. Eighth Report. Rockville, MD: United States Department of Health and Human Services. Druss, B. G., Marcus, S. C., Olfson, M., Tanielian, T. & Pincus, H. A. (2003). Trends in care by nonphysician clinicians in the United States. NEJM, 348(2), 130-137.

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GMENAC. (April 1981). Geographic Distribution Technical Panel, 3. DHHS Publication No. HRA-81-651. Washington, DC: United States Government Printing Office. Grumbach, K. (2002). The ramifications of specialty-dominated medicine. Health Affairs, 21(1), 155-157. Hart, L. G., Wagner, E., Pirzada, S., Nelson, A. F. & Rosenblatt, R. A. (January–February 1997). Physician staffing ratios in staff-model HMOs: A cautionary tale. Health Affairs, 55-89. Holahan, J. & Pohl, M. B. (2002). Changes in insurance coverage: 1994–2000 and beyond. Health Affairs, Web Exclusives 2002, W162–W171. Institute of Medicine. (1996). Primary Care: America’s Health in a New Era. Washington, DC: National Academies Press. Koenig, L., Siegel, J. M., Donson, A., Hearle, K., Ho, S. & Rudowitz, R. (2003). Drivers of healthcare expenditures associated with physician services. The American Journal of Managed Care, 9 (Special Issue 1): SP34–42. Medical Group Management Association. Cost Survey. Various years. Pew Health Professions Commission. (1995). Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century. San Francisco, CA. Reinhardt, U. E. (January–February 2002). Analyzing cause and effect in the United States physician workforce. Health Affairs, 21(1), 165-166. Weiner, J. P. (1994). Forecasting the effects of health reform on the United States physician workforce requirements: Evidence from HMO staffing patterns. JAMA, 20(3), 222-230. Weiner, J. P. (2002). A shortage of physicians or a surplus of assumptions? Health Affairs, 21(1), 160-162.

End Notes 1

The education, training, credentialing, and licensing of MDs and DOs is similar. The main difference between the two degrees is the DO emphasis on the musculoskeletal system and how an injury or illness in one area can affect another. 2 The AMA defines ―active‖ as working more than 20 hours per week in professional activities. The estimates provided in this paper include only physicians under age 75. 3 The PWS was conducted by The Sheps Center at the University of North Carolina on behalf of BHPr’s National Center for Health Workforce Analysis. Estimates of physician retirement rates were obtained via personal correspondence with Bob Konrad, principal investigator for the PWS.

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4

The CPW combines physicians, lawyers, accountants, architects, and other licensed professionals into an occupation entitled licensed professionals, and we estimate retirement rates for this group as a proxy for physician retirement patterns. 5 The Congressional Budget Office (CBO) projects a 3% annual growth rate in real Gross Domestic Product (GDP) between 2003 to 2013, which is about 2% average annual growth in real GDP per capita. Real economic growth, controlling for changing demographics, occurs through an increase in productivity. CBO projections, therefore, assume that worker productivity will increase by approximately 2% annually, on average, throughout the economy. Physician productivity will likely increase less rapidly than overall productivity in the United States due to the labor intensiveness of physician services. 6 More detailed supply projections are reported in The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand (BHPr, 2006). 7 To obtain hours worked per week by patient care specialty for the FTE conversion, we regressed the log of total hours worked per week (by post residency patient care MDs by specialty) on age variables, sex , and country of medical education (USMG,IMG) using 1998 data from the American Medical Association's Patient Care Physician Survey. The data contains estimates for 13 specialty categories: general/family practice, general internal medicine, medical subspecialties, general surgery, surgery subspecialties, general pediatrics, obstetrics/gynecology, radiology, psychiatry, anesthesiology, pathology, emergency medicine, and "other" specialties. Data for these specialties were mapped into the 37 specialties projected in the PSM. FTEs are defined to be equal to head counts in base year 2000, and thus for each specialty and physician type (USMG or IMG) the number of FTEs equals the head count in the base year. For each projection year, the number of physicians projected for each combination of physician type, specialty, sex and age is multiplied by the expected hours worked for the appropriate combination, and the sum of the products by specialty and physician type is divided by the baseline FTE definition in terms of hours worked per week for each specialty to produce projections of FTE physicians by year, physician type, and specialty. 8 Alternative approaches described in the literature to estimate physician requirements include a needs-based approach and use of benchmarking (i.e., a specific form of the utilization-based approach). The needs-based approach defines physician requirements based on a clinical assessment of prevalence rates for medical problems and the amount of time physicians need per patient encounter. This approach has been criticized because it ignores the economic realities that influence use rates. The benchmarking approach was used extensively in the 1990s by applying HMO physician-to-enrollee estimates to the United States population under a scenario with projected growth in managed care enrollment. 9 The eight categories are ages 0–4, 5–17, 18–24, 25–44, 45–64, 65–74, 75–84, and 85 and older. 10 As with the physician supply estimate, this count uses AMA and AOA Masterfile data on physicians’ activity status for physicians younger than age 75. 11 For the three insured categories, the PRM further distinguishes between private health insurers and government-sponsored insurance plans for a total of seven insurance categories. 12 Differences in healthcare systems make comparing use of physician services difficult. Also, measuring GDP and other measures of economic wellbeing across countries is an inexact science. 13 Over the past 20 years, the percentage of total Federal and nonfederal physicians engaged primarily in non-patient care activities has steadily declined from around 9% to its current level of about 6%. 14 Specialties hypothesized to be in this low-sensitivity category include general and family practice, general internal medicine, pediatrics, obstetrics/gynecology, and emergency medicine. 15 Specialties hypothesized to be in this medium-sensitivity category include cardiology, internal medicine subspecialties, general surgery, otolaryngology, urology, anesthesiology, radiology, pathology, and ―other‖ specialties.

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Specialties hypothesized to be in this high-sensitivity category include orthopedic surgery, ophthalmology, ―other‖ surgery, and psychiatry.

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Chapter 3

PRIMARY CARE PROFESSIONALS: RECENT SUPPLY TRENDS, PROJECTIONS AND VALUATION OF SERVICES

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Government Accountability Office WHY GAO DID THIS STUDY Most of the funding for programs under title VII of the Public Health Service Act goes toward primary care medicine and dentistry training and increasing medical student diversity. Despite a longstanding objective of title VII to increase the total supply of primary care professionals, health care marketplace signals suggest an undervaluing of primary care medicine, creating a concern about the future supply of primary care professionals— physicians, physician assistants, nurse practitioners, and dentists. This concern comes at a time when there is growing recognition that greater use of primary care services and less reliance on specialty services can lead to better health outcomes at lower cost. GAO was asked to focus on (1) recent supply trends for primary care professionals, including information on training and demographic characteristics; (2) projections of future supply for primary care professionals, including the factors underlying these projections; and (3) the influence of the health care system’s financing mechanisms on the valuation of primary care services.

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GAO obtained data from the Health Resources and Services Administration (HRSA) and organizations representing primary care professionals. GAO also reviewed relevant literature and position statements of these organizations.

WHAT GAO FOUND In recent years, the supply of primary care professionals increased, with the supply of nonphysicians increasing faster than physicians. The numbers of primary care professionals in training programs also increased. Little information was available on trends during this period regarding minorities in training or actively practicing in primary care specialties. For the future, health professions workforce projections made by government and industry groups have focused on the likely supply of the physician workforce overall, including all specialties. Few projections have focused on the likely supply of primary care physician or other primary care professionals.

Base year

Recent year

Average annual percentage change per capita

Primary care physicians Physician assistants Nurse practitioners Dentists

Number of primary care professionals per 100,000 people

Recent year

Number of primary care professionals Base year

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Supply of Primary Care Professionals

208,187

264,086

80

90

1.17

12,819 44,200 118,816

23,325 82,622 138,754

5 16 46

8 28 47

3.89 9.44 0.12

Sources: GAO analysis of data from HRSA’s Area Resource File and organizations representing primary care professionals. Notes: Data on primary care physicians are from 1995 and 2005. Data on physician assistants are from 1995 and 2007. Data on nurse practitioners are from 1999 and 2005. Data on dentists are from 1995 and 2007. Data for identical time periods were not available. The average annual percentage change is not sensitive to these time period differences.

Health professional workforce projections that are mostly silent on the future supply of and demand for primary care services are symptomatic of an

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Primary Care Professionals: Recent Supply Trends, Projections and … 85 ongoing decline in the nation’s financial support for primary care medicine. Ample research in recent years concludes that the nation’s over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care—all hallmarks of primary care medicine—can achieve improved outcomes and cost savings. Conventional payment systems tend to undervalue primary care services relative to specialty services. Some physician organizations are proposing payment system refinements that place a new emphasis on primary care services. GAO discussed the contents of this statement with HRSA officials and incorporated their comments as appropriate.

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Mr. Chairman and Members of the Committee: I am pleased to be here today as you prepare to consider the reauthorization of health professions education programs established under title VII of the Public Health Service Act.1 Most of the funding for title VII programs goes toward primary care medicine and dentistry training and increasing medical student diversity. Despite a longstanding objective of title VII to increase the total supply of primary care professionals, health care marketplace signals suggest an undervaluing of primary care medicine, creating a concern about the future supply of primary care professionals. As evidence, health policy experts cite a growing income gap between primary care physicians and specialists and a declining number of U.S. medical students entering primary care specialties— internal medicine, family medicine, general practice, and general pediatrics. Moreover, the federal agency responsible for implementing title VII programs, the Health Resources and Services Administration (HRSA), notes that physician ―extenders‖—namely, physician assistants and nurse practitioners— may also be choosing procedure-driven specialties, such as surgery, cardiology, and oncology, in increasing numbers.2, 3 A paradox commonly cited about the U.S. health care system is that the nation spends more per capita than all other industrialized nations but ranks consistently low in such quality and access measures as life expectancy, infant mortality, preventable deaths, and percentage of population with health insurance. Moreover, experts have concluded that not all of this spending is warranted, and overutilization of services can, in fact, lead to harm.4 These findings come at a time when there is growing recognition that greater use of

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primary care services and less reliance on specialty services can lead to better health outcomes at lower cost. To examine the supply of primary care professionals in more detail, you asked us to provide information related to the current and future supply of these professionals. My remarks today will focus on (1) recent supply trends for primary care professionals, including information on training and demographic characteristics; (2) projections of future supply for primary care professionals, including the factors underlying these projections; and (3) the influence of the health care system’s financing mechanisms on the valuation of primary care services. To discuss the recent supply trends for primary care professionals— including information on training and demographic characteristics—we obtained data from HRSA’s Area Resource File; the American Academy of Physician Assistants (AAPA); and the American Academy of Nurse Practitioners (AANP). In addition, we reviewed published data from AMA, the American Association of Colleges of Nursing (AACN); and the American Dental Education Association (ADEA).5 We also obtained published annual estimates from the United States Census Bureau on the noninstitutionalized, civilian population. To obtain information about projections of future supply of primary care professionals, we reviewed relevant literature and the position statements of organizations representing primary care professionals, including the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP). We also interviewed officials from HRSA, AAPA, AANP, the American Dental Association (ADA), and the Association of American Medical Colleges (AAMC). In selecting workforce supply projections for review, we focused on the projected estimates of national supply for primary care professionals from the past decade. To obtain information on the influence of the health care system’s financing mechanisms on the valuation of primary care services, we reviewed relevant literature on Medicare’s resource-based physician fee schedule and the influence of primary care supply on costs and quality of health care services. We assessed the reliability of HRSA’s Area Resource File data by interviewing officials responsible for producing these data, reviewing relevant documentation, and examining the data for obvious errors.6 We assessed the reliability of the data provided by the AAPA and the AANP by discussing with association officials the validation procedures they use to ensure timely, complete, and accurate data. We determined the data used in this testimony to

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Primary Care Professionals: Recent Supply Trends, Projections and … 87 be sufficiently reliable for our purposes. We discussed a draft of this testimony with HRSA officials. They provided technical comments, which we incorporated as appropriate. We conducted this work from December 2007 through February 2008, in accordance with generally accepted government auditing standards. In summary, in recent years, the supply of primary care professionals increased, with the supply of nonphysicians increasing faster than physicians. The numbers of primary care professionals in training programs also increased. Little information was available on trends during this period regarding minorities in training or actively practicing in primary care specialties. For the future, health professions workforce projections made by government and industry groups have focused on the likely supply of the physician workforce overall, including all specialties. Few projections have focused on the likely supply of primary care physician or other primary care professionals. Health professional workforce projections that are mostly silent on the future supply of and demand for primary care services are symptomatic of an ongoing decline in the nation’s financial support for primary care medicine. Ample research in recent years concludes that the nation’s over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care—all hallmarks of primary care medicine—can achieve improved outcomes and cost savings. Conventional payment systems tend to undervalue primary care services relative to specialty services. Some physician organizations are developing payment system refinements that place a new emphasis on primary care services.

BACKGROUND Among other things, title VII programs support the education and training of primary care providers, such as primary care physicians, physician assistants, general dentists, pediatric dentists, and allied health practitioners.7 HRSA includes in its definition of primary care services, health services related to family medicine, internal medicine, preventative medicine, osteopathic general practice, and general pediatrics that are furnished by physicians or other types of health professionals. Also, HRSA recognizes

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diagnostic services, preventive services (including immunizations and preventive dental care), and emergency medical services as primary care. Thus, in some cases, nonprimary care practitioners provide primary care services to populations that they serve. Title VII programs support a wide variety of activities related to this broad topic. For example, they provide grants to institutions that train health professionals; offer direct assistance to students in the form of scholarships, loans, or repayment of educational loans; and provide funding for health workforce analyses, such as estimates of supply and demand.8 In recent years, title VII programs have focused on three specific areas of need—improving the distribution of health professionals in underserved areas such as rural and inner-city communities, increasing representation of minorities and individuals from disadvantaged backgrounds in health professions, and increasing the number of primary care providers. For example, the Scholarships for Disadvantaged Students Program awards grants to health professions schools to provide scholarships to full-time, financially needy students from disadvantaged backgrounds, many of whom are minorities.

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Primary Care Education and Training Programs After completing medical school, medical students enter a multiyear training program called residency, during which they complete their formal education as a physician. Because medical students must select their area of practice specialty as part of the process of being matched into a residency program, the number of physician residents participating in primary care residency programs is used as an indication of the likely future supply of primary care physicians. Physician residents receive most of their training in teaching hospitals, which are hospitals that operate one or more graduate medical education programs. Completion of a physician residency program can take from 3 to 7 years after graduation from medical school, depending on the specialty or subspecialty chosen by the physician. Most primary care specialties require a 3-year residency program. In some cases, primary care physicians may choose to pursue additional residency training and become a subspecialist—such as a pediatrician who specializes in cardiology. In this case, the physician would no longer be considered a primary care physician, but rather, a cardiologist. According to the AAPA, most physician assistant programs require applicants to have some college education. The average physician assistant

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program takes about 26 months, with classroom education followed by clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and geriatric medicine. Physician assistants practice in primary care medicine, including family medicine, internal medicine, pediatrics, and obstetrics and gynecology, as well in surgical specialties. After completion of a bachelor’s degree in nursing, a nurse may become a nurse practitioner after completing a master’s degree in nursing. According to the AACN, full-time master’s programs are generally 18 to 24 months in duration and include both classroom and clinical work. Nurse practitioner programs generally include areas of specialization such as acute care, adult health, child health, emergency care, geriatric care, neonatal health, occupational health, and oncology. Dentists typically complete 3 to 4 years of undergraduate university education, followed by 4 years of professional education in dental school. The 4 years of dental school are organized into 2 years of basic science and preclinical instruction followed by 2 years of clinical instruction. Unlike training programs for physicians, there is no universal requirement for dental residency training. However, a substantial proportion of dentists—about 65 percent of dental school graduates—enroll in dental specialty or general dentistry residency programs.

SUPPLY OF PRIMARY CARE PROFESSIONALS INCREASED; LITTLE DATA AVAILABLE ON MINORITY REPRESENTATION In recent years, the supply of primary care professionals increased, with the supply of nonphysicians increasing faster than physicians. The numbers of primary care professionals in training programs also increased. Little information was available on trends during this period regarding minorities in training or actively practicing in primary care specialties.

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Government Accountability Office Table 1. Supply of Primary Care Professionals Number of primary care professionals

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Primary care physiciansa Physician assistantsb Nurse practitionersc Dentistsd

Number of primary care professionals per 100,000 people Base Recent year year

Average annual percentage change per capita

Base year

Recent year

208,187

264,086

80

90

1.17

12,819

23,325

5

8

3.89

44,200

82,622

16

28

9.44

118,816

138,754

46

47

0.12

Sources: GAO analysis of data from HRSA’s Area Resource File, AAPA, AANP, and the U.S. Census Bureau. Notes: Data on primary care professionals for identical time periods were not available. The average annual percentage change is not sensitive to these time period differences. a Data on primary care physicians include numbers for both MDs and DOs. Data for MDs are from 1995 and 2005, and for DOs are from 1995 and 2004. b Data on physician assistants are from 1995 and 2007. Data on the total number of physician assistants were obtained from AAPA, then weighted by using the percentage of physicians assistants who practiced primary care according to the 1995 AAPA membership survey and the 2007 AAPA physician assistant census survey. c Data on nurse practitioners are from 1999 and 2005. Data on the total number of nurse practitioners were obtained from AANP, then weighted by using the percentage of nurse practitioners who practiced primary care according to the AANP. d Data on dentists are from 1995 and 2007.

In Recent Years, Supply of Primary Care Professionals Increased In recent years, the number of primary care professionals nationwide grew faster than the population, resulting in an increased supply of primary care professionals on a per capita basis (expressed per 100,000 people). Table 1 shows that over roughly the last decade, per capita supply of primary care physicians—internists, pediatricians, general practice physicians, and family practitioners—rose an average of about 1 percent per year,9 while the per

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Primary Care Professionals: Recent Supply Trends, Projections and … 91 capita supply of nonphysician primary care professionals—physician assistants and nurse practitioners—rose faster, at an average of about 4 percent and 9 percent per year, respectively. Nurse practitioners accounted for most of the increase in nonphysician primary care professionals. The per capita supply of primary care dentists—general dentists and pediatric dentists—remained relatively unchanged. Growth in the per capita supply of primary care physicians outpaced growth in the per capita supply of physician specialists by 7 percentage points in the 1995-2005 period. (See table 2.) Table 2. Supply of Primary Care and Specialty Care Physicians, 1995 and 2005

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Number of physicians Primary care physicians Specialty care physicians All physicians

Number of physicians per 100,000 people 1995 2005

Percentage change per capita

1995

2005

208,187

264,086

80

90

12

468,843

553,451

181

189

5

677,030

817,537

262

280

7

Source: GAO analysis of data from HRSA’s Area Resource File. Note: Numbers do not add to totals due to rounding.

By definition, aggregate supply figures do not show the distribution of primary care professionals across geographic areas. Compared with metropolitan areas, nonmetropolitan areas, which are more rural and less populated, have substantially fewer primary care physicians per 100,000 people. In 2005, there were 93 primary care physicians per 100,000 people in metropolitan areas, compared with 55 primary care physicians per 100,000 people in nonmetropolitan areas.10 Data were not available on the distribution of physician assistants, nurse practitioners, or dentists providing primary care in metropolitan and nonmetropolitan areas.11

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Number of Primary Care Professionals in U.S. Training Programs Increased from 1995 to 2006

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For two groups of primary care professionals—physicians and nurse practitioners—the number in primary care training has increased in recent years. Over the same period, the number of primary care training programs for physicians declined, while programs for nurse practitioners increased. Comparable information for physician assistants and dentists was not available. From 1995 to 2006, the number of physician residents in primary care training programs increased 6 percent, as shown in table 3. Over this same period, primary care residency programs declined, from 1,184 programs to 1,145 programs. The composition of primary care physician residents changed from 1995 to 2006. A decline in the number of allopathic U.S. medical school graduates (known as USMD) selecting primary care residencies was more than offset by increases in the numbers of international medical graduates (IMG) and doctor of osteopathy (DO) graduates entering primary care residencies.12 Specifically, from 1995 to 2006, USMD graduates in primary care residencies dropped by 1,655 physicians, while the number of IMGs and DOs in primary care residencies rose by 2,540 and 1,415 physicians respectively. (See table 4.) Table 3. Number of Physicians in Residency Programs, in the United States, 1995 and 2006 Number of resident physicians

Primary care residents Specialty care residents All physician residents

1995

2006

38,753 59,282 97,416

40,982 63,897 104,526

Percentage change 6 8 7

Sources: AMA, ―Appendix II: Graduate Medical Education,‖ Journal of the American Medical Association (JAMA) vol. 276, no. 9 (September 1996) and ―Appendix II: Graduate Medical Education, 2006-2007,‖ JAMA vol. 298, no. 9 (September 2007). Notes: Primary care residencies include those for family medicine, internal medicine, pediatrics, internal medicine/family practice, and internal medicine/pediatrics.

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Primary Care Professionals: Recent Supply Trends, Projections and … 93 Table 4. Number of Physicians in Residency Programs, by USMDs, IMGs, and DOs, 1995 and 2006

Primary care residents Specialty care residents All physician residents Total (USMDs + IMGs + DOs)

USMDs 23,801

1995 IMGs 13,025

DOs 1,748

USMDs 22,146

2006 IMGs 15,565

DOs 3,163

45,300

11,957

1,585

47,575

12,611

3,466

69,101

24,982

3,333

69,721

28,176

6,629

97,416

104,526

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Sources: AMA, ―Appendix II: Graduate Medical Education,‖ JAMA vol. 276, no. 9 (September 1996) and ―Appendix II: Graduate Medical Education, 2006-2007,‖ JAMA vol. 298, no. 9 (September 2007). Note: Primary care residencies include those for family medicine, internal medicine, pediatrics, internal medicine/family practice, and internal medicine/pediatrics.

From 1994 to 2005, the number of primary care training programs for nurse practitioners and the number of graduates from these programs grew substantially. During this period, the number of nurse practitioner training programs increased 61 percent, from 213 to 342 programs. The number of primary care graduates from these programs increased 157 percent from 1,944 to 5,000.

Little Information Available Regarding Minorities in Training or Actively Practicing In Primary Care Specialties Little information was available regarding participation of minority health professionals in primary care training programs or with active practices in primary care.13 Physicians were the only type of primary care professional for whom we found information on minority representation. We found information not specific to primary care for physician assistants, nurse practitioners, and dentists identified as minorities, which may be a reasonable substitute for information on proportions of minorities in primary care. For physicians, we used the proportion of minority primary care residents as a proxy measure for minorities in the active primary care physician workforce. From 1995 to 2006, the proportion of primary care residents who

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were African-American increased from 5.1 percent to 6.3 percent; the proportion of primary care residents who were Hispanic increased from 5.8 percent to 7.6 percent. Data on American Indian/Alaska Natives were not collected in 1995, so this group could not be compared over time; in 2006, 0.2 percent of primary care residents were identified as American Indian/Alaska Natives. Minority representation among each of the other health professional types—overall, not by specialty—increased slightly. AAPA data show that from 1995 to 2007, minority representation among physician assistants increased from 7.8 percent to 8.4 percent. AANP data show that from 2003 to 2005, minority representation among nurse practitioners increased from 8.8 percent to 10.0 percent. ADEA data show that from 2000 to 2005, the proportion of African-Americans among graduating dental students rose slightly from 4.2 percent to 4.4 percent, while the proportion of Hispanics among graduating dental students increased from 4.9 percent to 5.9 percent. The proportion of Native American/Alaska Native among graduating dental students grew from 0.6 percent to 0.9 percent. Other demographic characteristics of the primary care workforce have also changed in recent years. In two of the professions that were traditionally dominated by men in previous years—physicians and dentists—the proportion of women has grown or is growing. Between 1995 and 2006, the proportion of primary care residents who were women rose from 41 percent to 51 percent. Growth of women in dentistry is more recent. In 2005, 19 percent of professionally active dentists were women,14 compared with almost 45 percent of graduating dental school students who were women.

UNCERTAINTIES EXIST IN PROJECTING FUTURE SUPPLY OF HEALTH CARE PROFESSIONALS; FEW PROJECTIONS ARE SPECIFICALLY FOR PRIMARY CARE Accurately projecting the future supply of primary care health professionals is difficult, particularly over long time horizons, as illustrated by substantial swings in physician workforce projections during the past several decades. Few projections have focused on the likely supply of primary care physician or nonphysician primary care professionals.

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History of Physician Workforce Supply Predictions Illustrates Uncertainties in Forecasting Over a 50-year period, government and industry groups’ projections of physician shortfalls gave way to projections of surpluses, and now the pendulum has swung back to projections of shortfalls again. From the 1950s through the early 1970s, concerns about physician shortages prompted the federal and state governments to implement measures designed to increase physician supply. By the 1980s and through the 1990s, however, the Graduate Medical Education National Advisory Committee (GMENAC), the Council on Graduate Medical Education (COGME), and HRSA’s Bureau of Health Professions were forecasting a national surplus of physicians. In large part, the projections made in the 1980s and 1990s were based on assumptions that managed care plans—with an emphasis on preventive care and reliance on primary care gatekeepers exercising tight control over access to specialists— would continue to grow as the typical health care delivery model. In fact, managed care did not become as dominant as predicted and, in recent years, certain researchers, such as Cooper,15 have begun to forecast physician shortages. COGME’s most recent report, issued in January 2005, also projects a likely shortage of physicians in the coming years and,16 in June of 2006, the AAMC called for an expansion of U.S. medical schools and federally supported residency training positions.17 Other researchers have concluded that there are enough practicing physicians and physicians in the pipeline to meet current and future demand if properly deployed.18

Few Projections Address Future Supply of Primary Care Professionals Despite interest in the future of the health care workforce, few projections directly address the supply of primary care professionals. Recent physician workforce projections focus instead on the supply of physicians from all specialties combined. Specifically, the projections recently released by COGME point to likely shortages in total physician supply but do not include projections specific to primary care physicians.19 Similarly, ADA’s and AAPA’s projections of the future supply of dentists and physician assistants do not address primary care practitioners separately from providers of

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specialty care. AANP has not developed projections of future supply of nurse practitioners. We identified two sources—an October 2006 report by HRSA and a September 2006 report by AAFP—that offer projections of primary care supply and demand, but both are limited to physicians.20 HRSA’s projections indicate that the supply of primary care physicians will be sufficient to meet anticipated demand through about 2018, but may fall short of the number needed in 2020. AAFP projected that the number of family practitioners in 2020 could fall short of the number needed, depending on growth in family medicine residency programs. HRSA based its workforce supply projections on the size and demographics of the current physician workforce, expected number of new entrants, and rate of attrition due to retirement, death, and disability. Using these factors, HRSA calculated two estimates of future workforce supply. One projected the expected number of primary care physicians, while the other projected the expected supply of primary care physicians expressed in fulltime equivalent (FTE) units. According to HRSA, the latter projection, because it adjusts for physicians who work part-time, is more accurate.21 The agency projected future need for primary care professionals based largely on expected changes in U.S. demographics, trends in health insurance coverage, and patterns of utilization. HRSA predicted that the supply of primary care physicians will grow at about the same rate as demand until about 2018, at which time demand will grow faster than supply. Specifically, HRSA projected that by 2020, the nationwide supply of primary care physicians expressed in FTEs will be 271,440, compared with a need for 337,400 primary care physicians. HRSA notes that this projection, based on a national model, masks the geographic variation in physician supply. For example, the agency estimates that as many as 7,000 additional primary care physicians are currently needed in rural and inner-city areas and does not expect that physician supply will improve in these underserved areas. In a separate projection, AAFP reviewed the number of family practitioners in the United States. AAFP’s projections of future supply were based on the number of active family practice physicians in the workforce and the number of completed family practice residencies in both allopathic and osteopathic medical schools. AAFP’s projections of need relied on utilization rates adjusted for mortality and socioeconomic factors. Specifically, AAFP estimated that 139,531 family physicians would be needed by 2020, representing about 42 family physicians per 100,000 people in the United States. To meet this physician-to-population ratio, AAFP estimated that family

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Primary Care Professionals: Recent Supply Trends, Projections and … 97 practice residency programs in the aggregate would need to expand by 822 residents per year. Both reports noted the difficulties inherent in making predictions about future physician workforce supply and demand. Essentially, they noted that projections based on historical data may not necessarily be predictive of future trends. They cite as examples the unforeseen changes in medical technology innovation and the multiple factors influencing physician specialty choice. Additionally, HRSA noted that projection models of supply and demand incorporate any inefficiencies that may be present in the current health care system.

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MOVE TOWARD PRIMARY CARE MEDICINE, A KEY TO BETTER QUALITY AND LOWER COSTS, IS IMPEDED BY HEALTH CARE SYSTEM’S CURRENT FINANCING MECHANISMS Health professional workforce projections that are mostly silent on the future supply of and demand for primary care services are symptomatic of an ongoing decline in the nation’s financial support for primary care medicine. Ample research in recent years concludes that the nation’s over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care—all hallmarks of primary care medicine—can achieve better health outcomes and cost savings. Despite these findings, the nation’s current financing mechanisms result in an atomized and uncoordinated system of care that rewards expensive procedure-based services while undervaluing primary care services. However, some physician organizations—seeking to reemphasize primary care services—are proposing a new model of delivery.

Payment Systems That Undervalue Primary Care Appear to Be Counterproductive Fee-for-service, the predominant method of paying physicians in the U.S., encourages growth in specialty services. Under this structure, in which physicians receive a fee for each service provided, a financial incentive exists

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to provide as many services as possible, with little accountability for quality or outcomes. Because of technological innovation and improvements over time in performing procedures, specialist physicians are able to increase the volume of services they provide, thereby increasing revenue. In contrast, primary care physicians, whose principal services are patient office visits, are not similarly able to increase the volume of their services without reducing the time spent with patients, thereby compromising quality. The conventional pricing of physician services also disadvantages primary care physicians. Most health care payers, including Medicare—the nation’s largest payer—use a method for reimbursing physician services that is resource-based, resulting in higher fees for procedure-based services than for office-visit ―evaluation and management‖ services.22 To illustrate, in one metropolitan area, Boston, Massachusetts, Medicare’s fee for a 25 to 30-minute office visit for an established patient with a complex medical condition is $103.42;23 in contrast, Medicare’s fee for a diagnostic colonoscopy—a procedural service of similar duration—is $449.44.24 Several findings on the benefits of primary care medicine raise concerns about the prudence of a health care payment system that undervalues primary care services. For example: Patients of primary care physicians are more likely to receive preventive services, to receive better management of chronic illness than other patients, and to be satisfied with their care.25 Areas with more specialists, or higher specialist-to-population ratios, have no advantages in meeting population health needs and may have ill effects when specialist care is unnecessary.26 States with more primary care physicians per capita have better health outcomes—as measured by total and disease-specific mortality rates and life expectancy—than states with fewer primary care physicians (even after adjusting for other factors such as age and income).27 States with a higher generalist-to-population ratio have lower perbeneficiary Medicare expenditures and higher scores on 24 common performance measures than states with fewer generalist physicians and more specialists per capita.28 The hospitalization rates for diagnoses that could be addressed in ambulatory care settings are higher in geographic areas where access to primary care physicians is more limited.29

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Some Health Care Reform Proposals Seek to Reemphasize Primary Care Medicine In recognition of primary care medicine’s value with respect to health care quality and efficiency, some physician organizations are proposing a new model of health care delivery in which primary care plays a central role. The model establishes a ―medical home‖ for patients—in which a single health professional serves as the coordinator for all of a patient’s needed services, including specialty care—and refines payment systems to ensure that the work involved in coordinating a patient’s care is appropriately rewarded. More specifically, the medical home model allows patients to select a clinical setting—usually their primary care provider’s practice—to serve as the central coordinator of their care. The medical home is not designed to serve as a ―gatekeeper‖ function, in which patients are required to get authorization for specialty care, but instead seeks to ensure continuity of care and guide patients and their families through the complex process of making decisions about optimal treatments and providers. AAFP has proposed a medical home model designed to provide patients with a basket of acute, chronic, and preventive medical care services that are, among other things, accessible, comprehensive, patient-centered, safe, and scientifically valid. It intends for the medical home to rely on technologies, such as electronic medical records, to help coordinate communication, diagnosis, and treatment. Other organizations, including ACP, the American Academy of Pediatrics (AAP), and AOA, have developed or endorsed similar models and have jointly recommended principles to describe the characteristics of the medical home.30 Proposals for the medical home model include a key modification to conventional physician payment systems—namely, that physicians receive payment for the time spent coordinating care. These care coordination payments could be added to existing fee schedule payments or they could be included in a comprehensive, per-patient monthly fee. Some physician groups have called for increases to the Medicare resource-based fee schedule to account for time spent coordinating care for patients with multiple chronic illnesses. Proponents of the medical home note that it may be desirable to develop payment models that blend fee-for-service payments with per-patient payments to ensure that the system is appropriately reimbursing physicians for primary, specialty, episodic, and acute care.

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CONCLUDING OBSERVATIONS In our view, payment system reforms that address the undervaluing of primary care should not be strictly about raising fees but rather about recalibrating the value of all services, both specialty and primary care. Resource-based payment systems like those of most payers today do not factor in health outcomes or quality metrics; as a consequence, payments for services and their value to the patient are misaligned. Ideally, new payment models would be designed that consider the relative costs and benefits of a health care service in comparison with all others so that methods of paying for health services are consistent with society’s desired goals for health care system quality and efficiency. Mr. Chairman, this concludes my prepared statement. I will be happy to answer any questions that you or Members of the committee may have.

End Notes 1

42 U.S.C. §§ 292 – 295p. Physician assistants are health care professionals who practice medicine under physician supervision. Physician assistants may perform physical examinations, diagnose and treat illnesses, order and interpret tests, advise patients on preventive health care, assist in surgery, and write prescriptions. Unlike physician assistants, nurse practitioners are licensed nurses who work with physicians and have independent practice authority in many states. This authority allows them to perform physical examinations, diagnose and treat acute illnesses and injuries, administer immunizations, manage chronic problems such as high blood pressure and diabetes, and order laboratory services and x-rays with minimal physician involvement. 3 For the purposes of this testimony, we considered primary care physicians to be those practicing in family medicine, general practice, general internal medicine, and general pediatrics. Some physician groups, such as the American Medical Association (AMA), consider physicians practicing in obstetrics/gynecology to also be primary care physicians. In addition, we considered general dentists and pediatric dentists to be primary care dentists. We defined primary care physician assistants as those practicing in family practice, general practice, general internal medicine, and general pediatrics. We defined primary care nurse practitioners as those practicing in adult, family, and pediatric medicine. Other types of health professionals, such as registered nurses, can provide primary care services in a variety of settings, but they were outside the scope of our review. 4 For example, noted studies show that Medicare spending for physician services varies widely by geographic areas and is unrelated to beneficiary health status. Elliott S. Fisher and H. Gilbert Welch, ―Avoiding the Unintended Consequences of Growth in Medical Care: How Might More Be Worse?‖ Journal of the American Medical Association, vol. 281, no. 5 (1999), 446-453; E.S. Fisher, et al., ―The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care,‖ Annals of Internal Medicine, vol. 138, no. 4 (2003), 273-287; E.S. Fisher, et al., ―The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,‖

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Primary Care Professionals: Recent Supply Trends, Projections and … 101 Annals of Internal Medicine, vol. 138, no. 4 (2003), 288-298; and Joseph P. Newhouse, Free for All? Lessons from the RAND Health Insurance Experiment (Cambridge, Mass.: Harvard University Press, 1993). 5 We obtained the most recently available data on supply for each professional group, the groups’ training programs, and the groups’ demographic characteristics. We compared the most recent data to a prior data point, in many cases 10 years earlier. For primary care physicians, we obtained data on supply for 1995 and 2005 from the Area Resource File and information on training and demographics from published AMA data for 1995 and 2006. For physician assistants, we obtained data on supply and demographic characteristics from AAPA for 1995 and 2007. For nurse practitioners, we obtained data on supply and demographic characteristics from AANP for 1999, 2003, and 2005 and information on training from published AACN data for 1994 and 2005. For dentists, we obtained data on supply for 1995 and 2007 from the Area Resource File and information on demographics from published ADEA data for 2000 and 2005. 6 Data from the AMA Masterfile and the American Osteopathic Association (AOA) Masterfile— on which data on physicians in the Area Resource File is based—are widely used in studies of physician supply because they are a comprehensive list of U.S. physicians and their characteristics. 7 Allied health professionals include, for example, audiologists, dental hygienists, clinical laboratory technicians, occupational therapists, physical therapists, medical imaging technologists, and speech pathologists. 8 For fiscal year 2007, funding for the title VII health professions programs was about $183 million. This excluded funding for student loans, which did not receive funds through the annual appropriation process. 9 Allopathic medicine is the most common form of medical practice. Graduates of allopathic medical schools receive doctor of medicine (MD) degrees. Osteopathic medicine is a form of medical practice similar to allopathic medicine that also incorporates manual manipulation of the body as a therapy. Graduates of osteopathic medical schools receive doctor of osteopathic (DO) medicine degrees. The number of primary care physicians includes both MDs and DOs. 10 Specialty care physicians are even more concentrated in metropolitan areas. In 2005, there were 33 specialty care physicians per 100,000 people in nonmetropolitan areas, compared with 200 specialty care physicians per 100,000 people in metropolitan areas. In total, there were 87 physicians per 100,000 people in nonmetropolitan areas and 293 physicians per 100,000 people in metropolitan areas in 2005. 11 One researcher, analyzing HRSA data, reported that in 2007 more than 30 million people were living in areas with too few dentists. Shelly Gehshan, ―Foundations’ Role in Improving Oral Health: Nothing to Smile About,‖ Health Affairs, vol. 27, no. 1 (2008). 12 Physicians who enter U.S. residency programs include graduates of both U.S. medical schools and foreign medical schools. Physicians from foreign medical schools—international medical graduates—can be citizens of other countries or U.S. citizens who attended medical school abroad. 13 HRSA’s Health Careers Opportunity Program defines underrepresented minorities as racial and ethnic groups that are underrepresented in the health professions relative to their numbers in the general population. According to HRSA, African Americans, Hispanics, American Indians, and Alaska Natives are underrepresented in the health professions. During the period we examined, minority representation increased among the general population. Specifically, from 1995 to 2006, the proportion of African-Americans in the general population increased from 12.0 percent to 12.3 percent; the proportion of Hispanics increased from 10.3 percent to 14.8 percent; and the proportion of American Indian/Alaska Natives increased from 0.7 percent to 0.8 percent.

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Government Accountability Office

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14

American Dental Association, ―Survey and Economic Research on Dentistry: Frequently Asked Questions‖ (Chicago, Ill.: American Dental Association), http://www.ada.org/ada/prod/survey/faq.asp (accessed Jan. 7, 2008). 15 Richard A. Cooper et al., ―Economic and Demographic Trends Signal an Impending Physician Shortage,‖ Health Affairs, vol. 21, no. 1 (2002). 16 COGME, ―Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020‖ (January 2005). 17 AAMC, ―AAMC Statement on the Physician Workforce‖ (June 2006). 18 David Goodman et al., ―End-Of-Life Care At Academic Medical Centers: Implications For Future Workforce Requirements,‖ Health Affairs, vol. 25 no. 2 (2006) and Jonathan P. Weiner, ―Prepaid Group Practice Staffing And U.S. Physician Supply: Lessons For Workforce Policy,‖ Health Affairs, Web Exclusive (Feb. 4, 2004). 19 COGME does not currently hold a position on the appropriate ratio of primary care physicians to specialty physicians. This is in contrast to the position COGME held from 1992 through 2004, which recommended that half of all physicians should be primary care physicians. 20 U.S. Department of Health and Human Services, HRSA, Bureau of Health Professions, ―Physician Supply and Demand: Projections to 2020‖ (October 2006) and AAFP, ―Family Physician Workforce Reform (as approved by the 2006 Congress of Delegates) Recommendations of the AAFP‖ (September 2006). 21 The FTE projection takes into account an expected decrease in the number of hours worked by physicians due to demographic workforce changes, including a greater share of female physicians and older physicians, some of whom are likely to work less than full-time. 22 Evaluation and management (E/M) services refer to office visits and consultations furnished by physicians. To bill for their service, physicians select a common procedural terminology (CPT) code that best represents the level of E/M service performed based on three elements: patient history, examination, and medical decision making. The combination of these three elements can range from a very limited 10-minute face-to-face encounter to a very detailed examination requiring an hour of the physician’s time. 23 The fee for this service in Boston, Mass., is represented on the fee schedule as CPT code 99214. 24 The fee for this service in Boston, Mass., is represented on the fee schedule as CPT code 45378. 25 A.B Bindman et al., ―Primary Care and Receipt of Preventive Services,‖ Journal of General Internal Medicine vol. 11, no. 5 (1996); D.G. Safran et al., ―Linking Primary Care Performance to Outcomes of Care,‖ Journal of Family Practice, vol. 47, no. 3 (1998); and A.C. Beal et al., ―Closing the Divide: How Medical Homes Promote Equity in Health Care: Results From The Commonwealth Fund 2006 Health Care Quality Survey‖ (The Commonwealth Fund, June 2007). 26 B. Starfield et al., ―The Effects Of Specialist Supply On Populations’ Health: Assessing The Evidence,‖ Health Affairs web exclusive (2005). 27 B. Starfield et al., ―Contribution of Primary Care to Health Systems and Health,‖ Milbank Quarterly, vol. 83, no. 3 (2005). 28 K. Baicker and A. Chandra, ―Medicare Spending, the Physician Workforce, and Beneficiaries’ Quality of Care,‖ Health Affairs web exclusive (2004). 29 M. Parchman et al, ―Primary Care Physicians and Avoidable Hospitalizations,‖ Journal of Family Practice, vol. 39, no. 2 (1994). 30 AAFP, AAP, ACP, AOA, ―Joint Principles of the Patient-Centered Medical Home‖ (March 2007).

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CHAPTER SOURCES

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The following chapters have been previously published: Chapter 1 – This is an edited, reformatted and augmented version of a United States Government Accountability Office publication, GAO-09-438R, dated May 4, 2009. Chapter 2 – This is an edited, reformatted and augmented version of a United States Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, dated October 2006. Chapter 3 – These remarks were delivered as testimony of A. Bruce Steinwald, Director, Health Care, before the Committee on Health Education, Labor, and Pensions, U.S. Senate, dated February 12, 2008. United States Government Accountability Office, publication GAO-08-472T.

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INDEX

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A AAP, 125 accountability, 119 accounting, 16 accreditation, 39 accuracy, 40, 71, 92 acute, 80, 109, 121, 122, 123 ADA, 27, 28, 29, 30, 39, 40, 41, 46, 105, 117 administration, 28, 36, 39, 45, 55, 81 adult, 32, 109, 123 African-American, 114, 115, 124 age, 38, 52, 53, 56, 57, 62, 63, 64, 65, 66, 71, 72, 75, 84, 90, 97, 98, 120 aggregate supply, 112 aging population, 84, 90 aid, 36, 37, 45 Alaska Natives, 114, 124 alternative, xiv, xv, 49, 51, 56, 67, 71, 85 altruism, 20 American Academy of Pediatrics (AAP), 121, 122 American Indian, 114, 124 anesthesiologist, 20, 75 appetite, 79 arteries, 46 assessment, 98

assumptions, xiv, xv, 49, 51, 71, 77, 91, 97, 116 auditing, 106 authority, 123 autonomy, 94

B baby boom, 72, 80 back, 70, 116 backlash, xv, 50 Balanced Budget Act, 14, 45 barriers, 80 base year, 52, 53, 86, 92, 98 behavior, 62 benchmarking, 98 benefits, 6, 56, 120, 122 blood, 46, 123 blood flow, 46 blood pressure, 123 bonus, 38 borrowers, 6, 25

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Index

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C cardiac surgery, 32 cardiologist, 3, 12, 108 cardiology, 3, 12, 15, 18, 74, 79, 84, 89, 91, 98, 104, 108 cardiovascular disease, 32 category a, 34 census, 25, 38, 63, 72, 73, 91, 105, 110 Census Bureau, 25, 38, 63, 72, 73, 91, 105, 110 Centers for Disease Control (CDC), 56 chronic illness, 120, 122 chronically ill, 103, 106, 119 citizens, 12, 55, 124 civilian, 105 classroom, 108, 109 clinical assessment, 98 clinics, 7 codes, 58 coinsurance, 74 collaboration, 94 colonoscopy, 120 communication, 121 community, 19, 78, 88, 93, 107 compensation, 37 competition, 94 competitiveness, 29 complexity, 19 components, 53, 58, 63, 71 composition, xiv, 50, 112 congress, viii, 14, 45, 125 Congressional Budget Office, 79, 97 consensus, xiii, xv, 5, 18, 49, 51, 94 continuity, 103, 106, 119, 121 control, xv, 51, 116 conversion, 98 correlation, 76, 78 cost saving, 103, 106, 119 cost-effective, xiv, 50 costs, xiv, 2, 14, 45, 46, 50, 106, 122 credentialing, 97

cross-sectional, 76, 77 Current Population Survey (CPS), 38, 56

D data analysis, 28 death, 52, 104, 117 debt, 3, 4, 5, 7, 10, 11, 15, 21, 22, 24, 25, 28, 29, 36, 38, 39, 40 decision making, 7, 125 decisions, 46, 70, 121 deductibles, 74, 76 definition, 92, 98, 107, 112 delivery, 71, 85, 86, 90, 92, 116, 119, 121 demographic characteristics, xiii, xvi, 5, 7, 15, 102, 105, 115, 123 demographics, 53, 71, 85, 94, 97, 117, 123 dentists, xv, xvi, 27, 28, 30, 39, 45, 46, 101, 103, 104, 107, 109, 110, 111, 112, 114, 115, 117, 123, 124 Department of Education, 2, 11, 23, 42, 47 Department of Health and Human Services, 41, 43, 95, 96, 125, 127 dermatology, 15, 34 diabetes, 123 diet, 78 disability, 52, 56, 117 disabled, 2 disadvantaged students, 2 diseases, 19 distribution, viii, 38, 53, 63, 71, 75, 93, 107, 112 diversity, xv, 101, 104 doctors, 18 draft, 6, 7, 43, 106 drugs, 45, 46 duration, 46, 109, 120

E earnings, 11, 38, 92 economic activity, 78

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Index economic growth, 76, 77, 78, 79, 85, 86, 93, 97 economic theory, 57 education, viii, xi, xiii, xiv, 1, 2, 6, 8, 9, 11, 13, 23, 27, 28, 36, 39, 40, 41, 42, 47, 50, 95, 96, 105, 108, 113, 114, 116, 127 educational attainment, 38 elasticity, 77, 79, 85 elasticity of demand, 77 elderly, xv, 2, 51, 72, 80 elderly population, 72 electrophysiology, 18 emergency medical services, 107 employers, 76, 78, 93 employment, 32 engagement, 4, 42 enrollment, 12, 98 enterprise, 91 environment, 7, 57, 58, 91 estimating, 53 ethnic groups, 124 examinations, 123 exclusion, 7, 35 expenditures, 77, 96, 120 exposure, 5, 19

F family, 5, 6, 7, 12, 15, 18, 20, 34, 47, 53, 59, 74, 98, 104, 107, 108, 111, 113, 114, 117, 118, 123 family medicine, 5, 6, 12, 15, 18, 20, 34, 47, 104, 107, 108, 113, 114, 117, 123 family physician, 118 family practice physician, 118 federal government, 2, 9, 46 fee, xv, 2, 4, 5, 22, 29, 37, 39, 51, 58, 74, 75, 105, 119, 120, 122, 125 fertility, 79 finance, 2 financial aid, 36, 37, 45 financial support, 103, 106, 119

107

financing, xiii, xvi, 102, 105, 119 fluctuations, 57, 93 focusing, 32 forecasting, 116 formal education, 108 funding, xiv, xv, 2, 5, 14, 45, 50, 101, 104, 107, 124

G GDP, 77, 78, 79, 97, 98 GDP per capita, 77, 78, 97 gender, 5, 20, 56 gene, 79 gene therapy, 79 general surgery, 12, 15, 34, 63, 74, 89, 91, 98 generation, 72 geriatric, 47, 108, 109 goals, 122 goods and services, 76 government, viii, xiv, 2, 9, 10, 14, 28, 39, 40, 41, 46, 50, 76, 78, 79, 80, 92, 93, 94, 98, 102, 106, 116 Government Accountability Office (GAO), xiii, xiv, 1, 50, 101, 127 graduate students, 14 grants, 107 Gross Domestic Product (GDP), 36, 37, 38, 39, 97 groups, 3, 11, 17, 33, 41, 46, 57, 59, 72, 74, 102, 106, 112, 116, 122, 123, 124 growth, xv, 51, 53, 59, 63, 70, 72, 76, 77, 78, 79, 81, 84, 85, 86, 88, 90, 91, 93, 94, 97, 98, 111, 117, 119 growth rate, 59, 63, 70, 97 guidance, 4, 41

H handling, 80 hanging, 94

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Index

hardships, 80 harm, 104 Health and Human Services (HHS), 6, 41, 43, 46, 95, 96, 125, 127 health care, xiii, xiv, xvi, 2, 10, 50, 57, 58, 76, 78, 79, 80, 85, 86, 90, 91, 94, 95, 96, 98, 101, 102, 103, 104, 105, 106, 116, 117, 118, 119, 120, 121, 122, 123 health care professionals, 123 health care system, xiii, xvi, 102, 103, 104, 105, 106, 118, 119, 122 health clinics, 7 health insurance, 104, 117 health services, 107, 122 health status, xv, 51, 123 high blood pressure, 123 higher education, 14 hispanics, 114, 115, 124 historical trends, 55 HMOs, xiv, 50, 74, 96 horizon, 71, 85 hospitals, 2, 7, 10, 13, 27, 58, 59, 65, 108, 121 house, 1, 2, 9 household, 76, 78

I imaging, 124 immigration, xiv, 50 immunology, 15 incentive, 38, 92, 119 incidence, 6 income, 2, 5, 6, 15, 24, 25, 30, 37, 38, 76, 77, 78, 85, 104, 120 indebtedness, 4, 29, 37 Indian, 115, 124 indication, 108 industry, 35, 38, 102, 106, 116 infant mortality, 104 inflation, 5, 21, 22, 29, 36, 37, 38, 39 infrastructure, xiv, 50

injury, viii, 97, 123 innovation, 118, 119 in-state, 22 institutions, 2, 10, 45, 70, 107 instruction, 109 insurance, 71, 72, 74, 75, 76, 78, 96, 98, 104, 117 internists, 111 interviews, 28, 33, 36, 46 invasive, 79

J JAMA, 95, 97, 113, 114

L labor, 92, 97 lawyers, 97 legislation, 45 lenders, 2, 46 licensing, 97 life expectancy, 104, 120 lifestyle, 5, 20, 40, 41 lifetime, 80 likelihood, 56 limitations, xv, 4, 42, 50, 77, 92, 94 linear, 78 listening, 95 loans, 2, 4, 5, 10, 14, 15, 23, 24, 25, 36, 41, 45, 46, 107, 124 location, 46, 71 low-income, 2

M maintenance, xiv, 50 management, 37, 120, 125 manipulation, 45, 46, 124 marital status, 5, 20 market, 7, 40, 86, 88, 92, 93 marketplace, xvi, 101, 104

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Index mask, 86, 89 measures, 52, 59, 98, 104, 116, 121 median, 5, 11, 21, 22, 36, 37, 38, 59 Medicaid, v, 2, 3, 10, 11, 38, 41, 42, 45, 58, 78 medical care, 7, 121 medical school, xiv, xv, 2, 3, 4, 5, 6, 10, 11, 12, 19, 33, 36, 37, 41, 45, 46, 47, 50, 51, 55, 56, 67, 70, 90, 108, 112, 116, 118, 124 medical services, 107 medical student, xv, 3, 4, 5, 6, 7, 11, 15, 22, 23, 33, 35, 36, 37, 40, 41, 46, 47, 101, 104, 108 Medicare, iii, 2, 3, 10, 11, 14, 38, 40, 41, 42, 45, 58, 105, 120, 122, 123, 125 medicine, xv, 3, 6, 7, 12, 15, 18, 19, 34, 35, 45, 46, 47, 53, 55, 74, 78, 80, 89, 91, 96, 98, 101, 103, 104, 106, 107, 108, 113, 114, 119, 120, 121, 123, 124 MEDLINE, 40 membership, 110 men, 56, 115 metropolitan area, 112, 120, 124 middle-aged, 57 military, 47 minorities, 102, 106, 107, 109, 114, 115, 124 models, xiv, 49, 55, 57, 71, 76, 92, 93, 94, 118, 122 mortality, 56, 94, 104, 118, 120 mortality rate, 56, 120 multiple factors, 18, 118 musculoskeletal, 97 musculoskeletal system, 97

N nation, 2, 103, 104, 106, 119, 120 National Health Service, 6 National Postsecondary Student Aid Study (NPSAS), 25, 36

109

Native American, 115 neonatal, 109 network, 74, 75 NIS, 75 normal, 76 NPSAS, 36, 38, 40 NRM, 3, 4, 11, 16, 17, 31, 32, 33, 34, 35, 37, 39, 40, 45, 46, 47 nurse, xvi, 101, 103, 104, 109, 110, 111, 112, 114, 115, 117, 123 nurse practitioners, xvi, 101, 103, 104, 110, 111, 112, 114, 115, 117, 123

O obligation, 6, 7, 14, 46 occupational, 109, 124 occupational health, 109 occupational therapists, 124 office-based, 65 oncology, 34, 38, 104, 109 oral, 7, 27, 28 osteopathy, 113

P paradox, 104 partnerships, 38 pathologists, 124 pathology, 7, 27, 34, 35, 74, 89, 91, 98 patient care, 45, 52, 54, 55, 57, 62, 63, 66, 72, 81, 84, 98 patient-centered, 121 patients, 58, 79, 80, 85, 92, 93, 120, 121, 122, 123 pediatric, 27, 28, 107, 111, 123 pediatrician, 108 pendulum, 116 per capita, xiii, 49, 72, 75, 76, 77, 78, 79, 84, 85, 91, 97, 102, 104, 110, 111, 120, 121 per capita income, 85 permanent resident, 55

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Index

personality, 20 personality traits, 20 pharmaceuticals, 94 physical therapist, 124 physician assistants, 103, 108, 110, 123 planning, 28 plastic, 15, 34 plastic surgery, 34 PLUS, 14, 24 policymakers, 80 population, xv, 51, 63, 71, 72, 73, 74, 75, 79, 80, 84, 90, 91, 98, 104, 105, 111, 118, 120, 124 population group, 75 population growth, 91 positive correlation, 76 postponement, 6, 25 postsecondary education, 36 PPO, 74 pre-clinical, 109 prediction, xv, 50 preference, 33, 35 premium, 45 pressure, 92, 123 prestige, 5 preventive, 78, 103, 106, 107, 116, 119, 120, 121, 123 price index, 36, 37, 38, 39 private, 2, 22, 28, 30, 39, 46, 58, 78, 98 private practice, 28, 39 private schools, 22 probability, 53, 56, 75 productivity, 57, 59, 66, 77, 85, 86, 91, 93, 94, 97 professions, 14, 38, 57, 102, 104, 106, 107, 115, 124 profits, 38 program, 2, 3, 7, 13, 14, 27, 28, 108 proxy, 77, 97, 114 prudence, 120 PsycINFO, 40 public, xiii, xv, 22, 27, 30, 50, 78, 79, 80 public health, 27, 78

Public Health Service, xv, 101, 104 public schools, 22

Q quality of life, 80

R radiation, 34 RAND Health Insurance Experiment, 123 range, 125 ratio analysis, 7, 35 recognition, xvi, 101, 104, 121 reforms, 122 registered nurses, 123 regulations, 41, 80 rehabilitation, 34 relationship, 76, 77, 78, 79 reliability, 38, 40, 106 retirement, 52, 53, 54, 56, 57, 92, 97, 117 retirement age, 53 revenue, 119 rewards, 119 rice, 36, 37, 38, 39 rotations, 108 rural, 7, 54, 88, 107, 112, 118 rural areas, 54

S safety, 14 salary, 4, 5, 20, 30, 38, 40, 41, 45 satisfaction, 57 saturation, 78 savings, 103, 107, 119 Scholarship Program, 6, 46 scholarships, 2, 6, 107 school, xiv, xv, 2, 3, 4, 5, 6, 10, 11, 12, 14, 19, 22, 27, 28, 29, 33, 36, 37, 39, 41, 45, 46, 47, 50, 51, 55, 56, 67, 70, 90, 107, 108, 109, 112, 115, 116, 118, 124

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Index school enrollment, 12 scores, 121 selecting, 5, 105, 113 self-report, 4, 36 senate, 127 sensitivity, 59, 98, 99 separation, 56, 92 series, 63, 76 sex, 52, 56, 71, 72, 75, 98 shortage, xiv, xv, 50, 51, 55, 63, 76, 86, 91, 92, 95, 97, 116, 117 short-term, 57, 71, 93, 94 signals, xvi, 101, 104 skills, 29 SMS, 57 socioeconomic, 7, 118 socioeconomic status, 7 specialization, 41, 55, 70, 109 speech, 124 staffing, xv, 50, 96, 97 standard error, 77 standards, 106 statistics, 58 student group, 17, 46 students, 2, 3, 4, 5, 6, 7, 10, 11, 12, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 28, 29, 33, 35, 36, 39, 40, 41, 45, 46, 47, 56, 104, 107, 108, 115 subsidy, 2 supervision, 3, 123 support staff, 59 surgeons, 32, 42 surgery, 3, 5, 12, 15, 19, 20, 27, 28, 31, 32, 34, 37, 38, 39, 40, 45, 46, 63, 74, 79, 89, 91, 98, 99, 104, 108, 123 surgical, 3, 4, 5, 6, 15, 16, 17, 19, 25, 32, 33, 35, 37, 38, 39, 54, 63, 74, 108 surplus, xiv, xv, 50, 63, 91, 92, 97, 116 systems, 98, 103, 107, 121, 122

111

T teachers, 45 teaching, 2, 28, 39, 45, 55, 81, 108 technicians, 124 technology, 79, 85, 118 telemedicine, 80 testimony, 106, 123, 127 therapy, 45, 46, 79, 124 thoracic, 3, 15, 31, 32, 39, 40 thoracic surgeon, 32 time, xiv, xvi, 7, 12, 36, 38, 40, 50, 52, 57, 58, 59, 71, 72, 77, 86, 91, 92, 98, 101, 103, 104, 106, 108, 109, 110, 115, 117, 119, 122, 125 time consuming, 59 time periods, 103, 110 training programs, 12, 13, 46, 102, 106, 109, 112, 114, 123 traits, 20 tuition, 2, 4, 5, 10, 22, 29, 37, 39, 46

U undergraduate, 2, 23, 36, 109 undergraduate education, 2, 36 uninsured, 75 university education, 109 urology, 34, 74, 84, 89, 91, 98

V validation, 106 variation, 36, 46, 47, 86, 91, 98, 118 Visa, 55 Visa Waiver Program, 55

W wealth, 57 web, 125

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X x-rays, 123

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wellbeing, 77, 78, 98 women, 5, 56, 57, 62, 93, 115 workers, 38, 58, 79, 93 workforce, xiv, 28, 50, 53, 56, 57, 62, 80, 91, 93, 95, 97, 102, 103, 105, 106, 107, 114, 115, 117, 118, 119, 125

Index

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