preparing for practice
TRANSCRIPT
• Work Force Overview - - - - - - - - - - - - - - - - - - Ronald P. Kaufman. M.D.• How to Interview and Assess Opportunities - - Janie Hirsch• Contract Negotiations - - - - - - - - - - - - - - - - - - William Kalist, J.D.
• Ten (10) 1 hour noon conferences from October 8, 2002 through February 19, 2003 at VA and TGH, covering:
• Pros and Cons of a Large Multi-specialty Group Practice• Small Group Practice• Leaving One Practice and Joining Another or Going into Solo Practice• How to Avoid Malpractice Suits• Proper Way to Apply for Full Medical Licensure in the State of Florida• Basic Financial Terms Part I• Basic Financial Terms Part II – will cover student loan repayment• Pursuit of Perfection• Gross Earnings vs. Spendable Income• Personal Financial Planning
• Risk Management – i.e. Malpractice Issues• Government Compliance Requirements• H.I.P.A.A.
Outline of Program “Getting A Job”
Students
Residents
SOURCE: AAMC Data Warehouse
31,137
38,529
41,003
43,020
46,968
46,591
45,365
42,808
37,410
33,301
29,243
31,137
38,529
41,003
43,020
46,968
46,591
45,365
42,808
37,410
33,301
29,2431990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
SOURCE: AAMC DATA Warehouse: 2000 Applicant Matriculant File
74737412
7162
6851
64336153
6772
6819694169186995
3000 4000 5000 6000 7000 8000
19901991199219931994199519961997199819992000
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
Net increase in U.S. medical graduatesentering the work force
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2020
2012
2014
2016
2018
2020
* Graduates are projected to retire after 35 years of practice.** Graduates from 1997-2020 are estimated to remain constant.
Estimated Retirements* National Graduates**
Source: MGT of America, Inc.From Assessment of the Adequacy andCapacity of Florida’s Medical Education System, 1999
YEAR M.D. DO DO as GRANTING GRANTING % of TOTAL
1970 40,487 2,151 5.0%1975 55,818 3,443 5.8%1980 65,189 4,940 7.0%1985 66,585 6,608 9.0%1990 65,163 6,792 9.4%1995 67,276 8,961 11.7%
26%
40%
20%14%Less than $50,000
$50,000 to $99,999
$100,000 to 149,999
$150,000 or more
Source: 1999 Medical School Graduation Questionnaire, All Schools Report - AAMC
80%
61%
21%
17%
15%
6%
15%
19%
26%
46%
89%
5%
Location
Financial package
Call/coverage
Lifestyle amenities
Loan forgiveness
Specialty support
(% ranking it first or second)
SOURCE: Merritt, Hawkins & Associates1999 Survey of Final-Year Medical Residents
1999
1997
(% citing it)
33% Multi-specialty group 25%29 Single-specialty group 3113 Partnership 15 4 Hospital employee 8 6 Outpatient clinic 8 2 Solo 4 5 Association ¹ 2 5 HMO 1 5 Other ² 6
1997 1999
¹ An arrangement whereby physicians share staff and office, but not finances.² Includes academic, locum tenens, urgent care, and no preference.
Source: Merritt, Hawkins & Associates 1999Survey of Final-Year Medical Residents
1995 199734%
22%
14%
14%
12%
3%
Finding a job Right practice setting Indebtedness Having free time
Malpractice climate Managed care Medicine as a career Health reform
1999
SOURCE: Merritt, Hawkins& Associates 1999 Survey of Final-Year Medical Residents
32%
21%
15%
13%
7%
5%
1%
FINDING A JOB31%
18%
13%
11%
10%
7%
FINDING A JOBRight Practice Setting
2% Anesthesiologists 10% 3% Radiologists 16% 3% Psychiatrists 16%10% Emergency medicine 4%11% IMs 8% 17% Others 22%54% FPs/GPs 13% Pediatricians 2% Cardiologists 2% Orthopedic Surgeon 3% Child psychiatrists 4%
1997 2001
NumberOf
DoctorsNeeded
U.S. Total needed12,098
U.S. Total needed12,098
The top 10 states with shortages of primary care doctors
Source: Bureau of Primary Health Care, Health Resources & Services Admin, US Dept. of Health and human Services
Texas1,103
Calif.757
Ohio372
N.Y.824
Mo.406
Ga.530
Ala.445
Ill.381
Mich.489
Fla. 631
U.S. Overall227
Idaho144
PhysiciansPer
100,000In
population
Alaska154
Nev.160
Okla.155
Wyo.156
Miss.148
Iowa156
S. D.170
Ark.175
Ind.178
States with the lowest doctor-to-population ratios
Source: American Medical Association
HMOpenetration
rate
States with the lowest HMO enrollment as a % of total population
Source: InterStudy Publications, US Census Bureau
United States (overall penetration) 29.7%
Alaska0%
Idaho.7.9%
Miss.1.1%
S.D.6.7%
Ala.7.2%
N.D.2.5%
Mont.7.0%
Iowa7.4%
Wyoming1.4%
VT4.6%
States with most physicians per capita States with fewest physicians per capita
District of
Columbia 811
Massachusetts 454
Maryland 413
New York 423
Connecticut 387
Idaho 179
Mississippi 180
Oklahoma 187
Alaska 186
Wyoming 188
• Job opportunities not as readily available as in the past
• Varies by specialty and varies by geography
• Shifts year to year• in demand• in compensation• in specialty opportunities
• Primary Care - demand and compensation flat
• Selective specialty demands will grow:• increase in procedural technology and demand
• radiology; cardiology; G.I.• increase in early retirement• aging of America
Reproduced from Lohr and Colleagues (5)
0
200
400
600
800
1000
1200
1400
1950 1960 1970 1980 1990 2000 2010 2020
Physicians per 100,000 Population
142.2 141.6
155.8
195.9
236.9
260.7
274.4
266.0
Su
pp
ly (
1000
s)
300.0
250.0
200.0
150.0
100.0
50.0
0.0
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
STUDY DATE CONCLUSION
Harry Truman 1945 ShortagePresident’s Commission 1953 ShortageBane Commission 1959 ShortageGMENAC 1980 SurplusCOGME 1988 SurplusBHP 1988 SurplusAMA 1988 ShortageCOGME 1993 SurplusPPRC 1993 SurplusPew Commission 1995 SurplusCOGME 1995 Specialist SurplusIOM 1996 Geographic VariationsSACHS 1996 Specialist Surplus/PCP ShortageJAMA 1996 Geographic VariationsCOGME 1997 SurplusAcademic Consensus 1997 SurplusMed PAC 1999 GME payment reform
DEFINITIONS:
GMENAC -Graduate Medical Education National Advisory Committee
COGME - Council on Graduate Medical Education
BHP - Bureau of Health Professionals
PPRC - Physician Payment Review Commission
Med PAC - Medicare Payment Advisory Commission
1929 2000 2010 2020
Physicians, total 144,000 772,000 887,300 964,700
Physicians/100,000 pop. 119 270 283 280
Population (in Millions) 121 286 325 345
Effective supply adjustment - 5% -7%
Storage of physicians 50,000 200,000
2010 and 2020 projected using Cooper, et al, Trend Model; assumes 1st-year residents holds steady at 23,000 a year, 20% of IMGS return to home country, and current retirement trends continue.Adjustment due to reduced work effort, including a 10% reduction in production by physicians ages 55 to65 and a 20% production reduction in women physicians (American Journal of Public Health, 1990).
Source: Health Affairs, January/February
I specialize in referrals to Specialists.
411
477523
577611687
267
271
237220195169
0
100
200
300
400
500
600
700
800
‘75 ‘79 ‘80 ‘83 ‘85 ‘87 ‘90 ‘91 ‘95 ‘96
Source: Kaiser Family Foundation analysis of American Hospital Association and U.S. Bureau of the Census data;and American Medical Association, Physician Characteristics and Distribution in the U.S., 1997-98 Edition.
Hospital Beds
Physicians
90,000
110,000
130,000
150,000
170,000
Source: AMA
$94,000
$100,000 $108,000
$120,000$125,000
$130,000 $139,000
$148,000$156,000
$150,000$160,000
$166,000
$164,000
(MGMA) Physician Compensation and Production Survey 1998 Report Based on 1997 Data
1991 1992 1993 1994 1995 1996 1997 1998
$500,000
$400,000
$300,000
$200,000
$100,000
Surgery: Cardiovascular
Cardiology: Invasive
Surgery: Orthopedic
Radiology: Diagnostic
Cardiology: Non-invasive
OBGYN
Surgery: General
Neurology
Internal Medicine
Pediatrics
Family Practice
195 (18) 151
(50
171(37)
189(31)
139(48)
157(45
151(44)183
(33)180(32)
147(47)
160(43)
146(46) 176
(35)206(16)
182(25)
180(30)
142(49)
173(40)
203(23)
130(51)
170(41)
180(36)
197(27)
208-(20) 176(38)
194(24)
180(39)
166(42)
200(22)
196(26)
190(29)
NH-189 (19)
NJ-249 (8)
202(15)
High Physician Concentration Areas
217(11)
203 (12)
221(14)
215(13)
208(17)
316(3)
246(9)
DC - 536 (1)
ME-182 (28)VT- 242 (7)
MA-332 (2)RI-267 (6)
M.D.- 299 (4)Del-197 (21)
CT-295 (5)
Source: AMA, Physician Characteristics & Distribution in the US,1996-97
Ratio of Physicians/100,000 Population
228(10)
179(34)
Low Concentration
Wash.
19%
Ore.Ore.
39%39% Idaho
7%
Mont.
5%
Wyo.
3%
S.D.5%
Iowa13% Neb.
11%
Kan.19%
Okla.15%
Ark.12%
Calif.
55%Calif.
55%
Nev.Nev.
25%25% Utah
37% Utah
37% Colo.
38%
Colo.
38% Ariz.
32% Ariz.
32% N.M.
37% N.M.
37%Alaska0%
Hawaii 45%
Texas
19% La. 17%
Miss.4%
Fla.33%
Ala.7%
Ga. 18%
Mo.31% Mo.31%
Tenn. 40%Tenn. 40%S.C. 12%
N.C. 17%
Va. 21% Va. 21%
W.V. 11%
Ky.38% Ky.38%
Ill.20%
Ind.17%
Ohio25%Ohio25%
Minn.
29% Minn.
29% Wis.31% Wis.31% Mich.
27%Mich. 27%
N.Y.38% N.Y.38%
Me.24% Me.24%Vt. 26%
N.H. 34%Mass. 42%R.I. - 50%
N.J.-29%
Md. - 34%Del. - 49%
Pa.45% Pa.45%
Conn.- 41%
All HMOs: 25% Source: Medical Data International Inc., April 2000
31% - 100% 21% - 30% 11% - 20% 0% - 10%
N.D.3%
MountainMountain$151,000$151,000
MountainMountain$151,000$151,000
West CentralWest Central$160,000$160,000
West CentralWest Central$160,000$160,000
New EnglandNew England$140,000$140,000
New EnglandNew England$140,000$140,000
Mid-Mid-AtlanticAtlantic$173,000$173,000
Mid-Mid-AtlanticAtlantic$173,000$173,000
East NorthEast NorthCentralCentral$164,000$164,000
SouthSouthAtlanticAtlantic$164,000$164,000
SouthSouthAtlanticAtlantic$164,000$164,000East SouthEast South
CentralCentral$175,000$175,000
East SouthEast SouthCentralCentral$175,000$175,000
PacificPacific$165,000$165,000
Source: Integrated Healthcare Report
110
120
130
140
150
160
170
Source: American Hospital Association
NOMINALREAL (1998 $)
($ In Thousands)
No shortage of Primary Care
No excess of Specialists
Decreasing interest in:• Internal Medicine• Pediatrics• Family Medicine
Geographic mal-distribution• Shift to the suburbs • Shift away from rural & inner city
Experts have been wrong in the past
Market adjusts
Technology
New Pathologies
Demographic changes
Consumerism
HMO?
IDS?
IPA? PA?
MSO?
*!#@?*
PHO? PPMC?
• Self-employed solo 25.9%• Self-employed group 30.7%• Employee:
Health maintenance organization 2.7%
Group practice, free-standing center 11.1%
Private hospital 7.3%
Medical schools, universities, colleges 7.0%
State and local government 9.6%
Unknown 1.1%• Independent contractor 4.7% *
1997 DISTRIBUTION OF PHYSICIANS BY PRACTICE TYPE AND EMPLOYER*
Source: AMA Center for Health Policy Research
Percentages do not sum to 100 because of rounding
Source: AMA Center for Health Policy Research
The AMA votes to organize a unionTOO MUCH FOR TOO FEW?AMA leaders say only a fraction ofpracticing physicians would beeligible to participate in an AMA-run collective bargaining unit:
The 290,000-member association -- whichrepresents 34 % of the nation’s doctors, down from 45% a decade ago -- also felt pressure to act because some of the most powerful unions have moved aggressively toorganize doctors, eroding the AMA’s base and making it seem timid to its members. Specifically, the AMA voted to set up a branch to unionize two groups of doctors, salaried employees and medical residents, who together represent about 1/3 of America’s 620,000 practicing physicians. The association also said it would work to unionize some of the 325,000 self-employed doctors, but to do that it must persuade Congress to give those doctors the right to bargain collectively. Eager to reassure patients, AMA See UNION, Page 7
CHICAGO - The American Medical Association bows to a growing chorus of physicians who say they lack power in managed care.
A Tribune staff, wire report
The American Medical Association,saying doctors are frustrated in efforts to deliver quality care, took the extraordinary step of forming a labor union Wednesday to give physicians more power in dealing with managed care insurers. For the 152-year old AMA, long one ofthe nation’s most conservative institutions,the vote at a delegates meeting represent-ed an angry outcry by doctors who complainthey have lost too much power in today'shealth care system.
Institutional Employees 26.6%
Employeesof MD-owned
Groups9.4%
Self-employedMDs64%
National Labor Relations Board v. Kentucky River Community Care, Inc.
Venue: U. S. Supreme Court
At Issue: The court said a professional who uses “independent judgment to direct the workof others is a supervisor who is unable to collectively bargain.
Potential Impact: The decision is expected tomake it more difficult for privately employedphysicians to unionize.
Source: National Conference of State Legislatures Pending legislationLegislation enacted
Source: Merritt, Hawkins & Associates
ManagedCare
56%
Medicare/Medicaid
regulation/billing: 15%
Patient attitudes: 8%
Malpractice worries: 6%
Pressure of running
a business: 6%
Long hours: 4%
Other: 5%
Retire38%
Retire38%
Continue as you are: 18%
Close your practice to new patients or significantly reduce
work load: 16%
Work locum tenens: 12%
Seek employment in non-clinical or non-medical
setting: 10%
Other: 4% Source: Merritt, Hawkins & Associates
N.E.J.M., Vol. .344, No. 3January 18, 2001
Clinicalknowledge
and skill
Understanding the health care system
Advocacyand
accountabilityfor
individualsand panels
Organizedpractice
managementsystems
Stewardship: Appropriate allocation of health careresources for quality care and cost effectiveness
• current and future opportunities and concerns
Outlined the program and its goals and objectives
Offered trend data on:
• numbers of M.D.s
• market forces at play
• compensation trend
• forces impacting choice