POTENTIAL SOLUTIONS POTENTIAL SOLUTIONS for the for the
EVOLVING PHYSICIAN SHORTAGEEVOLVING PHYSICIAN SHORTAGE
Richard A. Cooper, M.DRichard A. Cooper, M.D..
Florida Board of GovernorsOrlando
March 17, 2004
POTENTIAL SOLUTIONSPOTENTIAL SOLUTIONS--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Expand the infrastructure for undergraduate medical educationExpand the infrastructure for undergraduate medical education
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Expand the applicant poolExpand the applicant pool
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Expand residency (GME) training programsExpand residency (GME) training programs
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Increase the number of International Medical GraduatesIncrease the number of International Medical Graduates
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Increase the utilization of nonphysician cliniciansIncrease the utilization of nonphysician clinicians
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Streamline the processes of careStreamline the processes of care
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Improve the legal and regulatory environment for medical practiceImprove the legal and regulatory environment for medical practice
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EXPANSION OF MEDICAL SCHOOLSEXPANSION OF MEDICAL SCHOOLS
1.0
1.5
2.0
2.5
3.0
3.5
1940 1960 1980 2000
Total Matriculants
Graduates
Matriculants perpre-1960 school
Total Schools
MEDICAL SCHOOLS, MATRICULANTS MEDICAL SCHOOLS, MATRICULANTS and GRADUATES, 1940-2002and GRADUATES, 1940-2002
Allopathic and OsteopathicAllopathic and Osteopathic
1935-1940 = 1.0
CONTRIBUTIONS TO INCREASED NUMBERS OF MD CONTRIBUTIONS TO INCREASED NUMBERS OF MD MATRICULANTS AND GRADUATES, 1960 vs. 1980MATRICULANTS AND GRADUATES, 1960 vs. 1980
0%
25%
50%
75%
100%
Matriculants Graduates
% o
f Inc
reas
e in
M
atric
ulan
ts a
nd G
radu
ates
Decrease in studentattrition
Growth of pre-1960 classsize (82 schools)
Addition of new schools,1960-1980 (44 schools)
54%
45%
40%46%
15%
DEANS’ SURVEYDEANS’ SURVEYEXPANSION CAPACITY OF EXISTING MEDICAL SCHOOLSEXPANSION CAPACITY OF EXISTING MEDICAL SCHOOLS
-2.0
0.0
2.0
4.0
6.0
8.0
Percentage Change
Immediate or near termincreasesImmediate or near termdecreasesFuture capacity for increases
Total expansion capacity
SATELLITES and BRANCHESSATELLITES and BRANCHES
SATELLITE CAMPUSESSATELLITE CAMPUSES
Expand educational capacity of school Expand educational capacity of school
Distant from main campusDistant from main campus
Separate administrative structureSeparate administrative structure
Significant educational componentsSignificant educational components
Most developed in 1960s and 1970sMost developed in 1960s and 1970s
2828 schools with satellite clinical campuses schools with satellite clinical campuses
66 schools with satellite preclinical campuses schools with satellite preclinical campuses
BRANCH CAMPUSESBRANCH CAMPUSES
ALLOPATHIC MEDICAL SCHOOLSALLOPATHIC MEDICAL SCHOOLS
U of I branch at Urbana, Rockford, PeoriaU of I branch at Urbana, Rockford, Peoria
Cleveland clinic branch of Case-Western ReserveCleveland clinic branch of Case-Western Reserve
OSTEOPATHIC MEDICAL SCHOOLSOSTEOPATHIC MEDICAL SCHOOLS
Touro University (CA) branch at Las Vegas, NVTouro University (CA) branch at Las Vegas, NV
Philadelphia COM (PA) branch at Atlanta, GAPhiladelphia COM (PA) branch at Atlanta, GA
Lake Erie COM (PA) branch at Bradenton, FLLake Erie COM (PA) branch at Bradenton, FL
Western University (CA) branch planned ? whereWestern University (CA) branch planned ? where
APPLICANTSAPPLICANTS
BACHELOR’S GRADUATES and MEDICAL APPLICANTS BACHELOR’S GRADUATES and MEDICAL APPLICANTS
1940-2001 1940-2001
0
250,000
500,000
750,000
1,000,000
1,250,000
1,500,000
1940 1960 1980 2000
Bac
cala
urea
tes
.
Totalbaccalaureates
Medicalapplicants
NCES/AAMCNCES/AAMC
Medical Applicants
-50,000
-40,000
-30,000
-20,000
-10,000
- 0
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
1920 1930 1940 1950 1960 1970 1980 1990 2000
Women
Men
NCES, Table 171NCES, Table 171
BACHELOR’S DEGREES BACHELOR’S DEGREES 1920 to 20001920 to 2000
GI BillGI Bill 2.0M of the 3.4M who attended institutions of higher education under the GI Bill 1945-1965
Vietnam DraftVietnam Draft ~1M (14%) of the 7M men
who attended college during the Vietnam draft
1963-1978
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
1960 1970 1980 1990 2000 2010
Firs
t-tim
e M
edic
al A
pplic
ants
as
a p
erc
enta
ge o
f Bach
elo
r's D
egre
es
.
Men first time medicalapplicants perbachelor's degree (trend 1961-2001)
Women first timemedical applicants perbachelor's degree(trend 1985-2001)
AAMC/NCESAAMC/NCES
FIRST-TIME ALLOPATHIC MEDICAL SCHOOL APPLICANTSFIRST-TIME ALLOPATHIC MEDICAL SCHOOL APPLICANTSas a as a PERCENTAGEPERCENTAGE of BACCALAUREATE DEGREES of BACCALAUREATE DEGREES
1961-20011961-2001
0%
50%
100%
150%
200%
1975 1980 1985 1990 1995 2000
Per C
ent o
f 197
7 .
Bachelor'sDegrees
First-time MedicalApplicants
WHITE MALEWHITE MALEBACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTSBACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTS
1977-20001977-2000
0%
50%
100%
150%
200%
1975 1980 1985 1990 1995 2000
Per C
ent o
f 197
7 .
Bachelor'sDegrees
First-time MedicalApplicants
WHITE FEMALEWHITE FEMALEBACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTSBACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTS
1977-20001977-2000
0%
200%
400%
600%
800%
1975 1980 1985 1990 1995 2000
Per C
ent o
f 197
7 .
Bachelor'sDegrees
First-time MedicalApplicants
ASIANASIANBACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTSBACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTS
1977-20001977-2000
0%
100%
200%
300%
400%
1975 1980 1985 1990 1995 2000
Per C
ent o
f 197
7 .
Hispanic Bachelor'sDegrees
First-time MedicalApplicants
Black Bachelor'sDegrees
First-time MedicalApplicants
BLACKBLACKBACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTSBACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTS
1977-20001977-2000
STUDENTS MUST GRADUATE FROM HIGH SCHOOL STUDENTS MUST GRADUATE FROM HIGH SCHOOL TO GO TO COLLEGETO GO TO COLLEGE
….BUT EVEN THEN, THEY MIGHT NOT ….BUT EVEN THEN, THEY MIGHT NOT
40
50
60
70
80
90
100
Per
cent
.
Asian Female
Asian Male
White NH Female
White NH Male
Black Female
Black Male
Hispanic Female
Hispanic Male
Census Census Bureau Bureau Table A-5Table A-5
HIGH SCHOOL COMPLETERS HIGH SCHOOL COMPLETERS 1967-20001967-2000
0
100
200
300
400
500
1975 1980 1985 1990 1995 2000
Asian Women
Asian Men
White Women
White men
Black Women
Black Men
Hispanic Women
Hispanic Men
BACHELOR’S DEGREES PER CAPITABACHELOR’S DEGREES PER CAPITAPer 1,000 21-year oldsPer 1,000 21-year olds
0.0%
25.0%
50.0%
75.0%
100.0%
Hispanic
Black
White
Asian
RELATIVE PROPORTIONS of RELATIVE PROPORTIONS of WHITES, ASIANS, BLACKS and HISPANICSWHITES, ASIANS, BLACKS and HISPANICS
VARIOUS LEVELS OF EDUCATION, 1999-2000VARIOUS LEVELS OF EDUCATION, 1999-2000
Bureau of Bureau of the the
Census, Census, NCES, NCES, AAMCAAMC
BACHELOR’S GRADUATES BACHELOR’S GRADUATES
1961-2001 and projected to 20121961-2001 and projected to 2012
0
350,000
700,000
1,050,000
1,400,000
Totalbachelor'sdegrees
Womenbachelor'sdegrees
Menbachelor'sdegrees
NCESNCES
ProjectedProjected
FIRST-TIME MD APPLICANTSFIRST-TIME MD APPLICANTS1961-2001 and extrapolated to 20201961-2001 and extrapolated to 2020
Smoothed TrendSmoothed Trend
0
10,000
20,000
30,000
1960 1970 1980 1990 2000 2010 2020
First timeappl
First timefemale
First timemale
Sufficient forSufficient for5,000 additional5,000 additional
medical medical school school
acceptancesacceptancesat the marginat the margin
1. Creating sufficient numbers of high quality positions.1. Creating sufficient numbers of high quality positions.
2. Limitations of Balanced Budget Act of 1997” 2. Limitations of Balanced Budget Act of 1997” Positions frozen at 1996 levels.Positions frozen at 1996 levels.
3. Budget implications of additional positions:3. Budget implications of additional positions:Each new PGY-1 position will obligate Medicare to Each new PGY-1 position will obligate Medicare to
$35,000 in DME payments per year for an average $35,000 in DME payments per year for an average of 4.5 years). of 4.5 years). 5,000 positions = $800M5,000 positions = $800M
If IME payments are also allowed, each new first yearIf IME payments are also allowed, each new first yearposition will obligate Medicare to an additional $75,000 position will obligate Medicare to an additional $75,000 for 4.5 years. for 4.5 years. 5,000 positions = $1.5B5,000 positions = $1.5B
Total increase in Medicare GME at current rates would be:Total increase in Medicare GME at current rates would be: 5,000 positions = $2.3B5,000 positions = $2.3B
GME CHALLENGESGME CHALLENGES ------------------------------------------------------------------------
INTERNATIONAL MEDICAL GRADUATESINTERNATIONAL MEDICAL GRADUATES
IMGsIMGs(all years)(all years)
Citizenship or Visa StatusCitizenship or Visa Status
0
5,000
10,000
15,000
20,000
25,000
1985 1990 1995 2000
Year
IMG
s
Foreign
Native US
Naturalized US
Corrected for unknown
NON-US IMGsNON-US IMGsIndia, No Africa, Middle East vs the Rest of the WorldIndia, No Africa, Middle East vs the Rest of the World
0
1000
2000
3000
4000
1975 1980 1985 1990 1995
Indian subcontinent, NorthAfrica and Mid East
All other
ConcernsConcernsUS-IMGs vs. Foreign IMGsUS-IMGs vs. Foreign IMGsQuality of educational programsQuality of educational programsRate of disciplinary actionsRate of disciplinary actions
HurdlesHurdlesUSMLE Steps 1, 2, 3USMLE Steps 1, 2, 3Clinical Skills Assessment (CSA) (cost, time)Clinical Skills Assessment (CSA) (cost, time)Visas to take CSA examVisas to take CSA examVisas to enter for residencyVisas to enter for residencyDecreased availability of H1b visasDecreased availability of H1b visas(195K in 2003 (195K in 2003 65K in 2004) 65K in 2004)
CompetitionCompetitionEnglandEnglandCanadaCanadaAttractiveness of native countriesAttractiveness of native countries
IMG CHALLENGESIMG CHALLENGES
POTENTIALS and LIMITATIONS POTENTIALS and LIMITATIONS ofof
NONPHYSICIAN CLINICIANSNONPHYSICIAN CLINICIANS
OVERLAPPING RESPONSIBILITIES OFOVERLAPPING RESPONSIBILITIES OFPHYSICIANS AND NONPHYSICIAN CLINICIANSPHYSICIANS AND NONPHYSICIAN CLINICIANS
COMPLEX CARECOMPLEX CARE
MULTISYSTEM DISEASE CAREMULTISYSTEM DISEASE CARE
CHRONIC DISEASE MANAGEMENTCHRONIC DISEASE MANAGEMENT
MINOR and SELF-LIMITED DISORDERSMINOR and SELF-LIMITED DISORDERS
SYMPTOM CONTROLSYMPTOM CONTROL
WELLNESS CARE and PREVENTIONWELLNESS CARE and PREVENTION
COUNSELING and EDUCATIONCOUNSELING and EDUCATION
NONPHYSICIAN NONPHYSICIAN CLINICIANSCLINICIANS
PHYSICIANSPHYSICIANS
PROCESSES of CAREPROCESSES of CARE
Better information managementBetter information managementStreamlined flow of careStreamlined flow of care
Safer technologiesSafer technologies
vs. vs.
Onerous federal regulationOnerous federal regulationIntrusive managed care review Intrusive managed care review
Crippling malpractice litigation (Tort reform)Crippling malpractice litigation (Tort reform)
TIME FRAME OF POTENTIAL IMPACTTIME FRAME OF POTENTIAL IMPACT--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
10-1510-15 Expand Expand the infrastructure for undergraduate medical educationthe infrastructure for undergraduate medical education
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
10-1510-15 ExpandExpand the applicant pool the applicant pool
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
5-105-10 ExpandExpand residency (GME) training programs residency (GME) training programs
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
5-105-10 IncreaseIncrease the number of International Medical Graduates the number of International Medical Graduates
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
5-105-10 Increase the utilization of nonphysician clinicians Increase the utilization of nonphysician clinicians
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NowNow Streamline the processes of care Streamline the processes of care
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NowNow Improve the legal and regulatory environment for medical Improve the legal and regulatory environment for medical practicepractice
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECOMMENDATIONSRECOMMENDATIONS______________________________________________________________________________________________
• • Begin immediately to expand the infrastructure Begin immediately to expand the infrastructure for undergraduate medical education.for undergraduate medical education.
• • Expand residency training opportunities, especiallyExpand residency training opportunities, especially in the non-primary care specialties.in the non-primary care specialties.
• • Foster continued development of opportunities for Foster continued development of opportunities for NPs and other NPCs, particularly in primary care.NPs and other NPCs, particularly in primary care.
• • Examine the global impact of a continued Examine the global impact of a continued dependence on IMGs.dependence on IMGs.
• • Review the factors that affect practice efficiency Review the factors that affect practice efficiency and professional satisfaction among physicians. and professional satisfaction among physicians.
Thank you.