america faces allergy/ asthma crisis

AMERICA FACESALLERGY/ASTHMACRISISDemand for allergists willincrease 35% by 2020

Supply of allergistsexpected to decline

Attempts have failed todistribute allergists to areasof greatest need

The American College of AllergyAsthma & Immunology callsfor additional funding of A/IGME positions and innovativefederal initiatives

ALLERGISTALLERGISTREPORTREPORTREPORTPublished by The American College of Allergy, Asthma & Immunology

American College ofAllergy,Asthma & Immunology

The ACAAI is a not-for-profit professional 501(c) (3) association of 5,200allergist/immunologists. Established in 1942, the ACAAI is dedicated toimproving the quality of patient care in allergy and immunology throughresearch, advocacy and professional and public education.

Mission Statement

ACAAI promotes excellence in the practice of the subspecialty of allergyand immunology.

Vision Statement

ACAAI fosters a culture of collaboration and congeniality in which itsmembers work together and with others toward the common goals ofpatient care, education, advocacy and research.

American College of Allergy, Asthma & Immunology85 West Algonquin Road, Suite 550

Arlington Heights, IL 60005

Phone: (847) 427-1200Fax: (847) 427-1294

E-Mail: [email protected]

This publication made possible through unrestricted grants from:Alcon Laboratories, Inc. • Dey, L.P. • Teva Specialty Pharmaceuticals

3American College of Allergy, Asthma and Immunology — Graduate Medical Education and Workforce Issues in Allergy and Immunology

Executive Summary ......................................................4

Introduction ....................................................................5

Impact ofAllergic and Immunologic Diseases ..........6

Who will care forAsthma &Allergy Patients?ACAAI predicts a shortfall of more than2,100 allergists with no solution in sight ....................7

Distribution ofAllergy and ImmunologyTraining Programs by State..........................................8

Revenue Sources for Medical Education ....................9

Solutions to Increase the Number of Physicians........11

Solutions to Reduce PhysicianAttrition......................11

Alternative Sources of Funding GME Programs ......12

Solutions to Increase the SupplyofAllergist/Immunologists ............................................12

Conclusion ......................................................................15

Distribution of Allergyand ImmunologyTraining Programs byState 8

GraduateMedicalEducationand Workforce Issues inAllergy and Immunology

Solutions to Increasethe Supply of Allergist/Immunologists 12

Solutions toIncrease theNumber ofPhysicians 11

Executive SummaryCritical Shortage of AllergistsThere is a growing shortage of allergists in the United States. Without intervention, it is estimated

that the number of full-time equivalent (FTE) allergist/immunologists will decline about 7% from3,660 in 2006 to 3,400 in 2020. Meanwhile, demand for these physicians is projected to increase by35% over the same period (to more than 5,550 in 2020). New and larger residency programs areneeded in allergy and immunology to meet growing patient demand.

Allergic and Immunologic Diseases Have Become Much More CommonAsthma and other allergic diseases have become much more common in the United States in the

last 40 years. These diseases affect 40 to 50 million people or more than 20% of the population.Asthma alone has more than tripled over the past 25 years and affects more than 22 million people.

While asthma and other allergic diseases have grown dramatically, the number of allergist/immu-nologists is projected to fall because the number and size of training programs have decreased. Thereis also a growing shortage of primary care and other physicians who also provide care for people withallergic diseases.

In 1994, there were 85 allergy and immunology training programs in the U.S. Now, there are just71. Limited funding is cited as the primary reason for these drastic reductions which are projected tocontinue unless action is taken.

To keep pace with the growing demand for allergist/immunologists, training programs will need toincrease the number of specialists trained by an additional 120 per year.

Attempts to Solve the ProblemAttempts to solve the problem – which have fallen short of addressing the need – include: Self-

funding (no salary); support from practicing allergists; pharmaceutical industry funding; local endow-ment funds; funding by national allergy-immunology organizations; hospital funding and local, stateand federal funding.

Despite innovative funding mechanisms, policy changes are required at the national level to pro-vide additional support for Graduate Medical Education (GME) programs in allergy and immunology.

Action RequiredA coordinated public-private initiative to fund additional GME positions, including subspecialty

positions such as allergy and immunology, deserves the attention of federal policy makers. We atACAAI are eager to participate in efforts to find solutions for this pressing problem. It calls forimmediate action.

4 American College of Allergy, Asthma and Immunology — Graduate Medical Education and Workforce Issues in Allergy and Immunology

This white paper reviews the growingproblem of educating physicians to treatallergic diseases including asthma in theUnited States. It includes ACAAI’s sup-ply and demand forecast for allergistsand the geographic distribution of allergyand immunology training programs. Italso summarizes the evolution of federalpolicies with respect to Graduate MedicalEducation (GME), outlines strategyoptions for solving the physician shortageand presents ACAAI’s position onimproving patient outcomes in treatingallergic and immunologic diseases byincreasing the number of certified aller-gist/immunologists.

Our nation is facing a critical shortage ofcertified allergist/immunologists. Unlessaction is taken, there will not be enoughallergists to treat the growing number ofpatients who desperately need their care.The most effective response must combineprivate and public resources. We are dissem-inating this white paper to increase aware-ness of this critical problem, especiallyamong federal policy makers, in the hopethat concerned people working together willfind solutions.

Without intervention, it is estimated thatthe number of full-time equivalent (FTE)allergist/immunologists will decline 6.8%from 3,661 in 2006 to 3,413 in 2020, whiledemand for these physicians is projectedto increase by 35% to 5,558 in 2020.Moreover, there is a continuing andgrowing shortage of primary care physi-cians, who also provide care for peoplewith allergic diseases such as asthma, andof physicians in general.

Under current training and practice pat-terns, the Council on Graduate MedicalEducation (COGME) expects the supplyof practicing physicians in the U.S. to rise to971,800 full-time equivalent (FTE) physi-cians in 2020. At the same time, demand forphysicians is likely to grow even faster.COGME estimates that demand for physicianservices will range between 1,057,000 and1,068,000 physicians in 2020. Therefore, theprojected shortage of physicians ranges from85,000 to 96,000. Major factors drivingphysician demand include:

� Growth of the U.S. population. Anincrease of 50 million people (18%)is expected between 2000 and 2020.

� Aging of the population. It is estimat-ed that the number of Americans over65 will increase from 35 million in2000 to 54 million in 2020.

� Changing age-specific per capitaphysician utilization rates. Thoseunder age 45 will use fewer servicesand those over age 45 will use moreservices.

Large future needs require a largeresponse. The health care education systemneeds more medical colleges, more studentsper class, more residency slots and more resi-dency slots for specialties including allergyand immunology. The major factors con-straining physician supply and its ability togrow include the following:

� Very long lead times. Many years arerequired to increase physician supplydue to the length of training.

Growth of the U.S. population.An increase of 50 millionpeople (18%) is expectedbetween 2000 and 2020.

Allergic andImmunologicDiseaseshave become much more common

Introduction


in the United States in the last 20-40 years. Asthma affected 6.8million Americans in 1980, 13.7 million in 1994 and 22 million in 2005.While the number of Americans with allergic diseases includingasthma has grown dramatically, the number of allergist/immunologiststo treat these conditions is projected to fall because the number andsize of training programs has decreased.

� Capacity problems. There has beenno substantial medical schoolgrowth in 25 years.

� A significant shortfall in medicalschool slots. Some schools haveresponded in the last two yearswith modest growth of 8 to 10%.

� Massive medical student indebted-ness. This discourages qualifiedapplicants with limited resources.

� Capped residency positions. Thenumber of funded resident slots iscapped at 100,000 by the BalanceBudget Act of 1997. This cap doesnot apply to a residency programbut to a teaching hospital. For

example, if a hospital wants toexpand its residency program forallergy and immunology, it mustlower the number of internalresidents in another area.Furthermore, it should be notedthat subspecialty positions arereimbursed at only 50%.

� Restrictive Residency ReviewCommittee (RRC) requirements.Issues affecting RRC accreditationof residency programs affect theability of programs to maintainaccreditation or to expand, espe-cially with faculty shortages.

� Physician attrition. The Associationof American Medical Colleges

(AAMC) reports that one in everythree active doctors is likely to retireby 2020 and new generations ofphysicians are choosing to work lesshours.

The number of allergy and immunolo-gy training programs in the United Stateswas 85 in 1994. This figure decreasedto 72 by 2006 and dropped to 71 in 2007.The corresponding number of traineesdeclined 6% from 316 in 1994 to 298in 2007. Funding issues contributedto these reductions. New and largerallergy and immunology residencyprograms are needed to meet growingpatient demand. �

The challenge of managing asthmaand the other allergic diseases in theUnited States is becoming more difficult:

Asthma2

� Asthma, one of the allergic dis-eases, strikes 22 millionAmericans, including 7 millionchildren under age 18.

� The frequency of asthma increased75% from 1980-1994, as asthmarates in children under the age of 5rose more than 160%.

� In 2003, physician office visits andoutpatient visits due to asthmatotaled more than 12.7 million and1.2 million, respectively. Asthma-related visits to emergency depart-ments totaled more than 1.9 mil-lion in 2002.

� Deaths due to asthma exceed 5,000annually.

� Annual direct and indirect healthcare costs for asthma in the UnitedStates total more than $11.5 bil-lion and $4.6 billion, respectively.The combined total exceeds $16.1billion. The largest single directmedical expenditure is prescriptiondrug costs which exceed $5 billionannually.

� An estimated 12.8 million schooland 24.5 million work days aremissed annually due to asthma.

� Successful outpatient managementof asthma by an allergist/immunol-ogist can reduce emergency depart-ment visits, hospital admissions forasthma and asthma mortality. Thecost savings is significant.

� More than 70% of people withasthma also suffer from otherallergic diseases, such as rhinitisand atopic dermatitis (eczema).

Other Allergic Diseases3

� The various allergic diseases affectas many as 40 to 50 million peoplein the U.S. — more than 20% ofthe population.

� Allergic diseases are the sixth lead-ing cause of chronic disease in theUnited States.

� Allergic rhinitis (hay fever) affectsmore than 35.9 million people andaccounts for more than 14.1 mil-lion physician office visits eachyear.

� Overall costs related to allergicrhinitis in the United States wereapproximately $6 billion in 1996.

� In 1998, allergies cost more than$250 million due to absenteeismand reduced productivity.

� Nearly 35 million people areaffected by chronic sinusitis in theUnited States, which causes work-ers to miss an average of four daysof work each year and accounts formore than 18 million primary carephysician office visits.

� In 1996, health care expendituresattributable to sinusitis in the U.S.were estimated to be over $5.8 bil-lion.

� The most common skin conditionin children younger than 11 yearsof age is allergic dermatitis(eczema; itchy rash). Prevalencehas increased from 3% in the1960s to 10% in the 1990s.

� Hives affect 10 to 20 percent of thepopulation at some time in theirlives. Many (about 50%) continueto have symptoms for more thansix months. �


Impact of Allergicand Immunologic Diseases


Who Will Care for Asthma& Allergy Patients?ACAAI predicts a shortfall of more than2,100 allergists with no solution in sight

approximately 0.5 % per year between1999 and 2004, but the number of FTEsincreased as A/I physicians started topractice longer hours and lengthen theircareer to compensate for growingdemand. It should be noted that thetrend toward longer hours and lengthen-ing of careers is contrary to trends forphysicians in general.

Requirements for allergy/immunologyservices can be forecasted using simpleextrapolation (population ratios), trendanalysis (time series or regression), needsmodels which assume that non-insuredpatients will have the same utilizationpatterns as insured patients and demandmodels that take into account physicianproductivity and trends in demand forservices. ACAAI used a demand model,which was based on trends in office visitsas reported by the CDC and physicianproductivity expressed in office visits (66patient visits per week). Demand forallergists in FTEs is projected to increase35% from 4,109 in 2006 to 5,558 in2020. The supply of allergists in FTEs isexpected to decline 6.8% from 3,661 in2006 to 3,413 in 2020. Although theshortage of allergists does not affect allgeographic locations, it is widespread andgrowing worse.

The supply of allergist/immunologistswas forecasted by the American Academyof Allergy, Asthma and Immunology,through its 2000 Allergy and ImmunologyPhysician Workforce Survey conductedby SUNY-Albany’s Center for HealthWorkforce Studies. The 2000 workforcestudy identified two distinct groups ofphysicians that provide allergy-relatedservices: those whose practice is devotedexclusively or almost exclusively to pro-viding allergy and asthma-related servicesand physicians who provide these servic-es on a part-time basis and/or providenon-allergy related services as well. Coreallergists were defined as physicians pro-viding 30 or more hours per week inallergy and immunology patient care or20-29 hours per week if those hours rep-

resent a majority of a physician’s patientcare time per week. Core allergistsaccounted for 88% of allergist FTEs and86% of the estimated patient visits toallergists/immunologists.

A follow-up survey was sponsored byAAAAI and was conducted by SUNY-Albany’s Center for Health WorkforceStudies in 2004 to update the informationcollected 5 years ago, as well as to assessA/I physician perspectives on severaladditional issues to better understand theforces affecting U.S. A/I practices. Thenew survey shows that there were 4,245allergist/immunologists nationwide in2004 compared to 4,356 in 1999. Thestudy concluded that the number of aller-gist/immunologists declined at a rate of

ANALYSIS OF SUPPLY AND DEMAND FOR ALLERGIST/IMMUNOLOGISTS 4

Year Estimated Estimated Estimated Estimated Total Estimated EstimatedSupply of Supply of Capacity in Demand for Demand for Shortage of

A/I Physicians A/I FTEs Office Visits Office Visits A/Is in FTEs A/Is in FTEs1999 4,356 3,561 12,221,400 12,221,400 3,561 -2000 4,334 12,469,847 3,6332001 4,313 12,724,659 3,7082002 4,291 12,986,029 3,7842003 4,269 13,254,155 3,8622004 4,245 3,698 12,691,536 13,529,241 3,942 2442005 4,224 3,680 12,629,760 13,811,501 4,024 3442006 4,203 3,661 12,564,552 14,101,153 4,109 4482007 4,182 3,643 12,502,776 14,398,923 4,195 5522008 4,161 3,624 12,437,568 14,704,065 4,284 6602009 4,140 3,606 12,375,792 15,017,303 4,376 7702010 4,120 3,588 12,314,016 15,338,886 4,469 8812011 4,099 3,570 12,252,240 15,669,072 4,566 9962012 4,078 3,552 12,190,464 16,008,128 4,664 1,1122013 4,058 3,535 12,132,120 16,356,329 4,766 1,2312014 4,037 3,517 12,070,344 16,713,960 4,870 1,3532015 4,017 3,499 12,008,568 17,081,314 4,977 1,4782016 3,997 3,482 11,950,224 17,458,697 5,087 1,6052017 3,977 3,465 11,891,880 17,846,422 5,200 1,7352018 3,957 3,447 11,830,104 18,244,814 5,316 1,8692019 3,938 3,430 11,771,760 18,654,209 5,436 2,0062020 3,918 3,413 11,713,416 19,074,949 5,558 2,145Changefrom -6.8% -6.8% -6.8% +35.3% +35.3% Up 1,6972006

FTE increase between 1999 and 2004is due to A/I physicians practicing longerhours and lengthening their career.

Between0 and 244


In 2006, theAccreditation Councilfor Graduate MedicalEducation (ACGME)reported that 22 statesdid not have allergy andimmunology trainingprograms. Becausemany physicians have atendency to practice inthe communities wheretheir families live andwhere they were trained,all states with medicalschools should be tar-geted for placement oftraining programs. Thisstrategy should help todistribute allergists inrural and underservedareas. However, no def-inite plan or mechanismto distribute allergistsand other physicians toareas of greatest needhas been developed. �

Distribution of Allergyand ImmunologyTraining Programs by State

2006 ANALYSIS ON DISTRIBUTION OF ALLERGY AND IMMUNOLOGY TRAINING PROGRAMSState AAMC Resident Programs Approved Positions Residents on Duty

Medical Colleges (ACGME) (ACGME) (ACGME)Alabama 2 1 4 2Alaska - - - -Arizona 1 - - -Arkansas 1 - - -California 8 9 33 26Colorado 1 2 16 11Connecticut 2 1 3 1Delaware - - - -District of Columbia 3 1 8 8Florida 4 2 10 8Georgia 4 1 4 5Hawaii 1 - - -Idaho - - - -Illinois 7 2 14 14Indiana 1 - - -Iowa 1 1 3 3Kansas 1 1 4 3Kentucky 2 - - -Louisiana 3 3 15 14Maine - - - -Maryland 3 2 14 16Massachusetts 4 4 14 12Michigan 3 3 11 11Minnesota 2 2 6 6Mississippi 1 1 4 2Missouri 4 3 15 14Montana - - - -Nebraska 2 1 4 3Nevada 1 - - -New Hampshire 1 - - -New Jersey 2 1 6 4New Mexico 1 - - -New York 12 9 34 30North Carolina 4 3 14 7North Dakota 1 - - -Ohio 6 2 10 10Oklahoma 1 - - -Oregon 1 - - -Pennsylvania 6 5 21 17Rhode Island 1 - - -South Carolina 2 - - -South Dakota 1 - - -Tennessee 4 2 8 8Texas 7 4 25 25Utah 1 - - -Vermont 1 - - -Virginia 3 2 8 7Washington 1 1 4 -West Virginia 2 1 2 1Wisconsin 2 2 10 10Wyoming - - - -Total 122 72 324 278


Under current law, 44 separate Federalprograms support health care educationand training through individual and insti-tutional support authorized under thePublic Health Service (PHS) Act in titlesVII and VIII. The programs are adminis-tered by the Health Resources andServices Administration (HRSA) at theDepartment of Health and HumanServices (HHS).

Title VII of the PHS Act providesFederal support for education in thefields of allopathic and osteopathicmedicine, dentistry, veterinary medicine,optometry, podiatric medicine, chiroprac-tic, pharmacy, public health, graduateprograms in clinical psychology andhealth administration, physician assistanttraining and allied health. Title VIIprovides two forms of assistance: institu-tional support to medical colleges in theform of grants and contracts and studentassistance in the form of loans, loanguarantees, traineeships and scholarshipsfor students enrolled in these schools.Title VII appropriations peaked between1972 and 1974. Then they plateaued at$250 million per year (in 2006 dollars)between 1982 and 2005.5

GME influences the future of thehealth care system by determining thecomposition and competencies of thefuture physician workforce. The majorfunding initiatives that have influencedthe supply of physicians are listed below:

Health ProfessionsEducational Assistance Actof 1963The Health Professions Educational

Assistance Act of 1963 (P.L. 88-129),authorized a 3-year program for medicalschool construction and loan programsfor students in schools of medicine,dentistry and osteopathy. This initialenactment of federal support for educa-tion of health care professionals wasin response to a critical shortage ofmanpower and the 1963 legislationwas designed to increase enrollment atvarious medical schools and assure thefinancial viability of these schools.However, by the mid-1970’s whenstudies began to indicate that the supplyof health care professionals would besufficient to meet the nation’s futureneeds, the focus of support under titleVII began to change. Two areas of needwere emerging: first, rural and inner-city

communities experiencing shortages ofhealth care professionals and second, arelative shortage of primary careproviders. Support also was providedfor minority and disadvantaged studentsand area health education centers.

Subsequent extensions of Title VIIprograms began to focus federalinstitutional and student assistance toincrease the number of primary careproviders. In particular, the 1992reauthorization provided a preferencefor those programs, which trained thegreatest numbers of individuals whoenter practice in underserved areas.Despite these programs, distributionof physicians to areas of greatest needcontinues to be a problem.

Medicare ProgramImplementation – 1966In 1966, policymakers concluded that

it was inappropriate to pay the costs ofGME through Medicare funds. However,they also decided that until a permanentsource of funding for GME could befound, Medicare would pay its share ofthese costs because educational activitiesenhance the value of patient care. Aseries of commissions on the future of

Congress continues to be concerned withdeveloping a national health care workforcepolicy to: (1) improve the distribution andquality of the health care professionals need-ed to provide health services in underservedareas, (2) enhance the production and distri-bution of physicians to improve the state andlocal health infrastructure, and (3) provideaccountability based on uniformly agreedupon outcome measures. This policy couldbe achieved by improving the national supplyof physicians, improving the geographicdistribution of physicians in certain urban andrural areas and increasing minority represen-tation in the pool of practicing physicians.

RevenueSourcesfor Medical Education


Medicare have revisited this issueapproximately every four years and havereached the same conclusion.6

After Medicare, Medicaid is thesecond largest explicit payer of GME.States spend an estimated 7% ofMedicaid inpatient hospital expendituresto support GME.

Graduate Medical EducationNational Advisory Committee– 1981The prediction of a physician surplus

in the United States may be traced to the1981 Report of the Graduate MedicalEducation National Advisory Committeeto the Secretary, Departmentof Health and HumanServices. Following thisreport came a series of stud-ies in the 1980s and 1990s,often conducted on behalfof COGME, which reachedsimilar conclusions. Thesestudies indicated that by theyear 2000 there would be a15%-30% surplus of physi-cians (70,000 by 1990 and145,000 by 2000). It wasfurther concluded that thesurplus would be greater forspecialists and that therewould be some degree ofshortage for primary carephysicians. These studiesinfluenced a significant reduction in thesupply of physicians in the 1980s.Instead of the predicted surplus, we nowhave a significant shortage.

Why was the need for physicians sounderestimated? An answer to this ques-tion is given by Dr. Richard Cooper andcolleagues (Health Affairs 2002; 21:140-153). These writers argue that the modelsused in these studies were flawedbecause they were based on an analysisat the “micro” level. Studies focused onhow many physician FTEs would beneeded if they provided services accord-ing to good medical practice at an effi-cient rate, given a population with speci-fied demographics and associated healthrisks. Analysis of the adequacy of thephysician workforce, they argued, shouldnot be based on what the number ofphysicians ought to be in an idealizedworld. It should depend on the forcesthat are actually at work. In other words,the projected surplus did not materializebecause the idealized models neverplayed out in the real world.7

GME Payments Incorporatedinto the Medicare ProspectivePayment System – 1984In spite of the initial decision to only

temporarily fund GME from theMedicare Trust funds, funding for GMEremains in Medicare. Spending forGME has increased every year since1984, when explicit payments for GMEby the Medicare program were incorpo-rated into the Medicare prospectivepayment system.

Medicare pays hospitals for GMEthrough two payment streams – directGME payments and an indirect medicaleducation adjustment. Direct payments

compensate a teachinghospital for overheadcosts related to GMEand salaries and fringebenefits for residents,teaching physiciansand GME administra-tive staff. The indirectmedical educationadjustment compen-sates teachinghospitals for the higheroperating costs associ-ated with the presenceof a residency programsuch as more compli-cated cases, additionaltests ordered by

residents as part of the learning processand reduced patient care productivity byall staff members. Medicare GME spend-ing has remained flat. In 2002, 2003 and2004, direct-GME averaged $2.6 billionand indirect-GME averaged $5.6 billionper year.8

Health Profession EducationExtension Amendments –1992With the passage of the Health

Profession Education ExtensionAmendments of 1992, Congress restruc-tured Title VII of the Public HealthService Act to fund programs to encour-age primary care and promote ethnic andracial diversity among physicians.

Workforce Development Act –1999In 1999, Congress authorized approxi-

mately $300 million in annual grantsto support workforce development.Funding for these programs has fluctuat-ed in recent years, but has generallyremained in the $300 million range.Authorized programs include the follow-ing: guaranteed loans for the educational

cost of physicians, nurses, pharmacistsand other health care professionals; directloans through medical, pharmacy andother professional schools for minoritystudents who agree to complete a residen-cy in primary care and to practice in suchfields until the loan is repaid; scholarshipsfor students of exceptional financial need;support for area health centers; fellow-ships in family medicine, general internalmedicine, general pediatrics and supportfor allied health care professionals.

Additional Federal FundingSourcesThere are 130 Veteran’s Affairs med-

ical centers that have affiliation agree-ments with 105 medical schools. Nearly32,000 residents receive some training ina VA facility each year. The VA funds8,900 residency positions, or about 10%of the nation’s residency slots. It alsoprovides partial salary support for teach-ing physicians who provide patient care,supervise residents and perform researchat VA medical centers. Affiliation andfinancial arrangements between the VA,other teaching hospitals and medicalschools are negotiated on a hospital-by-hospital basis. The VA has recentlyannounced a plan to fund additionalresidency training. Allergy programscould comprise some of these additionalslots or programs.

The Department of Defense and theNIH also provide GME funding. It isdifficult to estimate the level of financialsupport because the GME payments arenot always separately identifiable. Thetotal amount could be $1 to 2 billion.Most NIH programs, however, fund posi-tions for future researchers, rather thanclinicians or clinician-educators.9

Third-Party PayersIn the past, third-party payers, whose

payments were based on hospitalcharges, implicitly supported GMEthrough higher payments to teachinghospitals. As managed care plansachieved high market penetration, theywere generally less willing to paythese higher amounts and the level ofprivate-payer support for GME declined.However, some managed care companiesreport that they continue to pay higherrates to academic health centers. It isdifficult to determine how much GMEsupport private insurers currently pro-vide. Estimates are that managed careplans pay 5 -10% more to teaching hos-pitals than to community hospitals.11 �


On a macro level, population growth,the number of Baccalaureate andMedical Degrees and the number ofresidency programs and slots drive thesupply of physicians. These can beviewed as a series of levers in sequentialorder. The number of practicing physi-cians is driven by career opportunities inclinical practice versus those inresearch, education and industry. Policymakers can develop a variety of strate-gies to enable each of the drivers. �

Solutions to Increasethe Number of Physicians

Solutions to ReducePhysician AttritionOn a macro level, early retirements,

physician death rates and careerchanges drive reductions in the supplyof physicians. Departures can bereduced by improving job satisfaction,removing liability concerns, encourag-ing healthier lifestyles and workingfewer hours (through improvements inproductivity). �

Drivers of Physician Supply Enablers Factors that Federal and StatePolicy Makers Can Influence

Population Growth Birth RateImmigration Immigration Policy

Baccalaureate Degrees Growth of 1-18 Age GroupU.S. Economic Growth National and Local EconomyJob Prospects Job CreationCollege Capacity Growth of State CollegesStudent Funding Options Student Loans and SubsidiesCollege Attrition Rate

Medical Degrees Physician Job Prospects Job Creation in Health Care includingDiversity and Rural Programs

Positive Image of PhysiciansPotential Economic Rewards Tort ReformStudent Funding Options Student Loans and SubsidiesMedical College Capacity Funding of Medical CollegesMedical College Attrition Rate

Residency Programs and Slots Number of Programs and Slots Funding GME

Specialty Certifications Job Prospects by SpecialtySpecialty Slot Capacity Funding GME for Critical Specialties

Such as Allergy / ImmunologyHospital Needs and ROI

Practicing Physicians Incentives Supporting Clinical Practice Balancing Support for PhysicianPlacements in Clinical Practice,Research, Academia and Industry

Drivers of Physician Attrition Reasons Factors that PolicyMakers Can Influence

Early Retirements Declining Job SatisfactionLiability Concerns Tort ReformWorking Long Hours Increasing the Supply and Use of Nurse

Practitioners, Physician Assistants andother Non-Physician Clinicians

Death Rates Stress and Lifestyle Encouraging Healthier Lifestyles

Career Changes Cost of Liability Insurance Tort ReformDesire to Work Fewer Hours Technology Breakthroughs


ACAAI evaluated the following strat-egy options to address the shortfall ofallergist/immunologists:

Self-FundingUnder this scenario, fellows are obli-

gated to work fulltime in a training pro-

gram, but are not paid. They are expect-ed to secure their own income by what-ever means they can. This is the histori-cal model for fellowship funding. Manycurrent allergists were trained this way.

Advantages — The satisfaction of doingit yourself.

Disadvantages

� Accreditation requirements addressresident employment and salaryissues.

� This concept has limited appeal.Fellows have completed college,

Solutions to Increase the Supplyof Allergist/Immunologists

In their excellent review of the policydebate on graduate medical education,10Gerald F. Anderson, George D. Greenbergand Barbara O’Wynn identified theseproposals:

� An all-payer fund to support GMEwas proposed by the late SenatorDaniel Patrick Moynihan (D-NY).Legislation would establish anall-payer fund using Medicarepayment methodologies. Theproposal called for non-Medicarefunding through a 1.5% tax onprivate health insurance premiumsand ERISA plans as well as atransfer of 5% of federal spendingfor Medicaid acute care. Theseresources would supplement exist-ing Medicare funds and would beallocated according to currentMedicare payment formulas.

� In 1999, a special committee ofthe Bipartisan Commission onReform of Medicare recommend-ed that GME be removed from theentitlement portion of Medicareand appropriated directly. This

proposal would separate GMEfunds from patient care paymentsand make the recipients moreaccountable for the funds.Opposition came from teachinghospitals, who argued that thisplan did not provide stable fund-ing for education.

� The Medicare Payment AdvisoryCommission (MPAC) proposedeliminating Medicare’s explicitpayments for GME, and combin-ing GME costs with other patientcare costs. The MPAC also pro-posed adopting Diagnosis RelatedGroup (DRG) refinements thatwould pay hospitals caring formore severely ill patients at higherrates while operating within abudget-neutral system. Medicare’sprospective payments would beadjusted to reflect the higher costsof providing enhanced patient carein teaching hospitals not paidthrough the refined case-mix sys-tem. Under this plan, current sub-sidies for teaching hospitals would

continue to be paid throughpatient care funds and hospitalswith the most severely ill patientswould receive a greater share offunds.

� The Association of AmericanMedical Colleges (AAMC)continues to call for the removalof the cap on the number ofresidency training programsfunded by Medicare. “Increasedpublic support of graduate medicaleducation is essential to guaranteea sufficient supply of doctors tocare for the growing number ofelderly,” said AAMC PresidentJordan J. Cohen, M.D.

Health care economists, policymakersand hospital mangers have debated waysto calculate the incremental cost ofGME. The rationale and methods forcalculating the cost of GME haveevolved over time. Additional work isrequired to develop a better method forsetting Medicare payment rates forGME. �

There have been numerous calls over the years to find alternative sources of fundingfor GME. Private-sector funding has been explored many times. Although there hasbeen general agreement that GME is a public good, there has been no consensus onpolicy issues relating to financing.

Alternative FundingSources for GME Programs

medical school and a three-yearresidency in pediatrics or internalmedicine. They have already accu-mulated substantial debt. They areat least 28-30 years old. Many oftheir college friends have hadwell-paying jobs for many years.

� Many fellows have spouses andchildren to support making self-funding requirements unattainable.

� Grants for clinical allergy andimmunology training appear to befew and far between.

� Unless they are independentlywealthy, fellows would also haveto make a substantial moonlight-ing commitment that would inter-fere with the reading commitmentof fellowship training.

� This model could create disparitiesby attracting a high percentage offellows from wealthy families.

Support from PracticingAllergistsThis option requires an allergy prac-

tice or an individual to make a donationthat covers expenses for a 2-year allergyand immunology fellowship. A specific,named fellow is paid from the donationat a salary equivalent to other institution-al PGY-4 and PGY-5 salaries.

Advantages

� The fellow is paid at the same rateas peers in other subspecialtyfellowships.

� This may serve as an excellentrecruiting tool for the practice.

Disadvantages

� Accreditation requirements addressresident selection issues.

� An agreement needs to be madeto ensure that the entire grant isreceived or otherwise guaranteedbefore the fellow signs an institu-tional training contract.

� When the donor is an allergypractice group, it is likely that thefellow would be contractuallyobligated to join that practice aftertraining, and repay the cost oftraining over a period of time.If, in the course of training, thefellow decides not to join thatpractice, there could be issues.This potential event would have tobe addressed prospectively in anyagreement between the fellow and

the allergy practice, as well as inthe fellow’s contract with the insti-tution.

� Fellow candidates with this kind offunding would have an unfairadvantage over more highly quali-fied candidates without funding.

Pharmaceutical IndustryFundingPharmaceutical companies can be

approached to provide educational grantsto institutions to fund training.

Advantages

� Funding is available at manypharmaceutical companies foreducational grants.

� The fellow is paid the same rateas peers in other subspecialty pro-grams.

Disadvantages

� There can be perceptions of stringsattached to educational grants.

� There can be a clear potential forconflict of interest. Even in thebest of circumstances, it is notclear how there could not be somesense of obligation on the part ofthe fellow, faculty, or institution.

Local Endowment FundsFormer fellows from a training

program, foundations and other interest-ed private donors can contribute to a uni-versity endowment fund. The incomefrom this fund provides income forfellows-in-training.

Advantages

� Development campaigns can bedesigned to secure funds.

� Security is a major advantage.

Disadvantages

� To generate $60,000 per year totrain one fellow, there needs to beat least $1.2 million in principal.

� The endowment fund must beprotected to prevent diversion offunds to other programs.

� There must be a plan in place todetermine what will happen to theendowment account in the eventthat the allergy and immunologytraining program closes for somereason.

Funding by National Allergy-Immunology OrganizationsBoth the American College of Allergy,

Asthma & Immunology (ACAAI) andthe American Academy of Allergy,Asthma and Immunology (AAAAI) havefoundations and other sources of fundsthat can be used for fellowship training.

Advantages

� Some funds are currentlyavailable.

� Additional funds can be raised.

Disadvantages

� Funding would support a verylimited number of fellows.

� Association resources would bediverted from other importantareas.

Hospital FundingSubspecialty training can be funded

from local university hospital budgets.

Advantages

� There would be perceived andactual “equality” with otherprograms in the institution.

� Having local control is preferableto federal control over how train-ing might be conducted.

Disadvantages

� The cognitive, non-procedural,outpatient-based specialties do notgenerate substantial income forthe hospital or university.

� In the specific case of allergy andimmunology, many universitypractices do not give the practi-tioner credit for income generatedby skin testing or immunotherapyinjections because these do nothave a physician work component.

� Allergy/immunology is an outpa-tient-based specialty. Admission ofa patient to the hospital is consid-ered a failure of outpatient man-agement.

� Emergency room and inpatientcharges for management of acuteasthma are readily reimbursed bythird-party payers. Patients withmild or moderately severeepisodes of asthma do not requiresubstantial resources for inpatientmanagement.



� From the viewpoint of hospitalmanagement systems, fundingallergy and immunology trainingmight be considered disadvanta-geous.

Local, State and FederalFundingFederal funds were once the major

source for subspecialty funding, beforethey were reduced by the BalancedBudget Act of 1997. Many states fundGME through the Medicaid program.

Advantages

� There would be perceived andactual “equality” with otherprograms in the institution.

� Good outpatient care costs the gov-ernment less in the long run.

� Multiple sources of funding areavailable.

Disadvantages

� NIH funding is for training tomor-row’s scientists, and clinician-scientists.

� There is no clear program for train-ing tomorrow’s clinician-educators in academic medicalcenters.

In summary, programs are attemptingto address the shortfall of allergist/immunologists through several mecha-nisms with limited success. They arefalling short of addressing the need. In2007, the number of trainees increased to298, covering only a very small portionof the shortfall. Despite innovativeapproaches in funding, it is unlikely thatthe problem will be addressed withoutpolicy changes at the national level thatprovide additional support for GME pro-grams in allergy and immunology. �

Endnotes

1 The supply forecast started with the 1999 to 2004trend line in the American Academy of Allergy, Asthmaand Immunology’s 2004 Workforce Study. Projectionsfrom 2004 to 2020 were prepared by ACAAI.

2 Sources for data in this section include:• American Lung Association. Epidemiology &Statistics Unit, Research Program and Services.Trends in Asthma Morbidity and Mortality, May 2005.

• Summary Health Statistics for U.S. Children:National Health Interview Survey, 2002. Series 10,Number 221.2004-1549.

• Centers for Disease Control. Surveillance forAsthma – United States, 1960 – 1995, MMWR. 1998;47 (SS-1).

• National Library of Medicine. UnderstandingAllergy and Asthma. National Institutes of Health,Website, 2006.

3 Sources for data in this section include:• American Academy of Allergy, Asthma andImmunology (AAAAI). The Allergy Report: ScienceBased Findings on the Diagnosis & Treatment ofAllergic Disorders, 1996-2001.

• American Academy of Allergy, Asthma andImmunology Task Force on Allergic Disorders.Executive Summary Report. (1998).

• Nathan, R.A., Meltzer, E.O., Selner, J.C., Storms, W.“Prevalence of Allergic Rhinitis in the United States.”Journal of Allergy and Clinical Immunology (1997)99:S808-14.

• United States Centers for Disease Control andPrevention. National Center for Health Statistics.National Ambulatory Medical Care Survey; 2002Summary, table 13.

• Ray, N.F., Baraniuk, J.N., Thamer, M., et al: Healthcare expenditures for sinusitis in 1996: contributionsor asthma, rhinitis and other airway disorders. J. ofAllergy Clin. Immunology, 103 (3 Pt 1): 408-514,1999.

• Hewitt Associates LLC. The Effects of Allergies inthe Workplace. 1998.

• CDC, Vita and Health Statistics, Current Estimatesfrom the National Health Interview Survey, 1994(U.S. Department of Health and Human Services,Public Health Service, National Center for HealthStatistics): DHHS Pub. No. PHS 96-1521, December1995.

• Horan, R.F., Schneider, L.C., Sheffer, A.L. “AllergicDisorders and Mastocytosis.” Journal of the AmericanMedical Association. (1992) 268:2858-2868.

4 Data for 1999 and 2004 in the first column wasderived from the American Academy of Allergy,Asthma and Immunology’s April 2006 press releaseon the 2004-2005 A/I workforce survey conducted bythe Center for Health Workforce Studies, StateUniversity of NewYork-Albany. Data for all otheryears in column one was an ACAAI extension of thetrend line from the 2004-2005 A/I workforce survey(1999 to 2004).

FTE data for 1999 and 2004 in column two wasderived from the American Academy of Allergy,Asthma and Immunology’s 2004-2005 A/I workforcesurvey. The study concluded that A/I physicians havecompensated for their shrinking numbers by practic-ing longer hours per week and lengthening theircareer. This resulted in an increase in the FTE countbetween 1999 and 2004. (It should be noted that thetrend toward longer hours and lengthening of careersis contrary to trends for physicians in general.) It wasassumed that FTE’s would decline after 2004 at thesame rate as A/I physicians.

Supply data was also utilized from the AmericanAcademy of Allergy, Asthma and Immunology’s Allergyand Immunology Physician Workforce Report 2000,Figure ES-1; www.aaaai.org

Demand in column four is based on the assumptionthat one third of patient visits are for asthma and thatthese visits to allergists will double every 20 yearssimilar to the pattern reported by CDC(http://healthandenergy.com/asthma_increasing.htm), an average 3.5% annual increase;

also assumes that non-asthma allergy office visits willgrow at an average of 1.3% per year similar to thepattern reported by CDC for all visits(http://www.cdc.gov/nchs/pressroom/01news/olderpat.htm).

5 Fitzhugh Mullan, MD, George Washington University,“FatYears, LeanYears and the Need to Reinvent TitleVII,” presented at the AAMC Physician WorkforceResearch Conference: 2020 Vision, Focusing on theFuture, May 4-5, 2006, Washington, DC.

6 Graduate Medical Education: The Policy Debate,Gerald F. Anderson, George D. Greenberg andBarbara O Wynn, Annual Review of Public Health,Vol. 22: 35-47 (Volume publication date May 2001),page 38, 2001.

7 David S. Guzick, MD, PhD, Deans’Newsletter,University of Rochester Medical Center,October 28, 2004.

8 The American Medical Student Association,“Graduate Medical Education Funding,” 2005, p.3.

9 Anderson, Greenberg and Wynn, p.38.

10 Ibid.

11 Ibid.

ConclusionThere is a growing shortage of aller-

gist/immunologists in the United States.ACAAI estimates that the number ofallergist/immunologists (FTEs) willdecline 6.8% from 3,661 in 2006 to 3,413in 2020, while demand for these physi-cians is projected to increase by 35% to5,558 in 2020. New and larger residencyprograms are needed in allergy andimmunology to meet growing patientdemand. Some programs can train morefellows. They should be identified andfinancially supported. Many programscannot expand. Therefore, the number oftraining programs in the system needs toincrease to balance supply and demand.

The shortage of allergist/immunolo-gists is part of the general shortage ofphysicians. An expansion in medical edu-cation and federal initiatives will be need-ed to address chronic problems in short-ages of specialty physicians (suchas allergist/immunologists), shortages ofprimary care physicians, physician distri-bution and workforce diversity.

Citing growing evidence of a nationalphysician shortage, the Association ofAmerican Medical Colleges (AAMC)recommends that enrollment in medicalschools be increased 30% by 2015. Thisexpansion would result in an additional5,000 new M.D. students annually andshould be accomplished by boostingenrollment at existing schools, as well asby creating new allopathic medicalschools.

ACAAI Position: IncreaseSupply of Allergists by120 AnnuallyCurrent supply cannot keep up with the

current retirement and death rate of prac-ticing allergists. To cover attrition (anestimated net loss of 20 allergists peryear) and to keep up with new demand(a need for 100 additional allergists eachyear), training programs (existing andnewly established) should increase theannual production rate by 120allergy/immunology physicians.

A coordinated public-private initiativeto fund additional GME positions, includ-ing subspecialty positions such as allergyand immunology, now deserves the urgentattention of federal policy makers. We atACAAI are eager to participate in effortsto find solutions for this pressing prob-lem. It calls for immediate action.

ACAAI GME/WorkforceCommitteeJohn Moffitt, MD (Chair)

Susan Rudd Bailey, MD

Gailen Marshall, MD, PhD

William D. McClendon, MD

Jay M. Portnoy, MD

Richard Weber, MD


American College of Allergy, Asthma & Immunology85 West Algonquin Road, Suite 550

Arlington Heights, IL 60005Phone: (847) 427-1200Fax: (847) 427-1294www.acaai.org

This publication made possiblethrough unrestricted grants from:

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america faces allergy/ asthma crisis

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