The Troubled Physician Workforce:Is a physician surge the answer?

David C. Goodman, MD MS

Professor of Pediatrics and ofCommunity and Family Medicine

The Center for the Evaluative Clinical SciencesDartmouth Medical School

Hanover, NH

2007 National Health Policy Conference

CECSCenter for the EvaluativeClinical Sciences

What are the desired outcomes of medical workforce policy?

• Access to care when it is wanted and needed.

• Care that is technically excellent and personally compassionate.

• Care that improves the health and well being of patients and populations.

• Care that is affordable to the patient and to society.

The 2020 “Shortfall” and the Remedy

COGME. Sixteenth Report. 2005.

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

Supply Demand Need

1,076,000

972,000

1,240,000

1,027,00

1,173,000

1,086,000

Physician Supply, Demand, and Need in the U.S. 2020

Shortfall = ~90,000 or ~10%

Council on Graduate Medical Education:

Increase medical school enrollment by 15%.

Increase or remove Medicare Graduate Medical Ed. cap.

American Association of Medical Colleges:

Increase medical school enrollment by 30%.

Eliminate the Medicare GME cap.

The Per Capita Supply of Physicians Varies ~300% Across Regions

30

40

50

60

70

80

90

100

110

50

75

100

125

150

175

200

225

250Specialists Generalists

Post-GME clinicians per 100K population age sex race adjusted - 1996

Dartmouth Atlas Hospital Referral Regions

10%

300%

Regional variation in physician supply is not explained by:

• Patient health status or health riskChan R, et al. Pediatrics 1997.Goodman D, et al. Pediatrics 2001.Wennberg J. Ed. Dartmouth Atlas of Health Care. Various editions. 1996 - 2006.Fisher E, et al. Ann Int Med 2003.

Example 1: Are Neonatologists located where newborn needs are greater?

8.57 to 25.64 (50)6.39 to 8.57 (49)4.88 to 6.39 (51)3.55 to 4.88 (46)0.56 to 3.55 (51)

Neonatologists per 1,000 Live Births

Neonatologists

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0

5

10

15

20

25

30

4 5 6 7 8 9 10 11 12 13

Percent Low Birth Weight

Neo

nat

olo

gis

ts p

er 1

0,00

0 b

irth

s

R2=0.04

Goodman, et al. Pediatrics, 2001.

Example 1: Are Neonatologists located where newborn needs are greater?

There is virtually no relationship

between regional physician supply and health needs.

2.0

4.0

6.0

8.0

10.0

12.0

3.0 6.0 9.0 12.0 15.0 18.0

AMI Rate per 1,000 Medicare Enrollees

Car

dio

log

ists

per

100

K

Source: Wennberg, et al. Dartmouth Cardiovascular Atlas

There is virtually no relationship

between regional physician supply and health needs.

Example 2: Are Cardiologists located where cardiac needs are greater?

Regional variation in physician supply is not explained by:

• Patient health status or health risk• Patients preference for care

Fisher E, et al. Ann Int Med 2003.NIA-CMS beneficiary survey, forthcoming.

No difference in preferences for aggressive care (dying in hospital, mechanical ventilation, or drugs that would lengthen their life, but make them feel worse)

No differences in concerns about getting too little (or too much) treatment

Somewhat lower preference for palliative care that would shorten life (80% want it in low spending regions, 75% in high spending).

So what?

Maybe more physicians leads to better health outcome.

Example 3: Do areas with higher physician supply have better health outcomes?

Source: Goodman, et al. New Engl J Med, 2002

• Logistic models 1995 USbirth cohort

• N = 3.8 million live births

• Dependent variable:28 day mortality

Very Low Low Medium High Very High0.8

0.9

1

1.1

Mortality Odds ratio

Quintile of Physician Capacity

Neonatologists

Better Outcomes Inefficient Care

Beyond a very low supply, outcomes are

insensitive to physician supply.

Last 6 Months of Life Chronic Disease Medicare Cohorts(Full Time Equivalents per 1,000 beneficiaries)

Total Primary Care

Medical Specialists

NYU Medical Center 28.3 FTE 8.8 FTE 15.0 FTE

RWJ University Hosp 19.8 4.3 12.2

Montefiore Med Center 16.5 6.5 7.1

MA General Hospital 15.3 6.3 5.5

Johns Hopkins Hospital 12.2 5.0 3.9

Yale-New Haven 10.6 3.4 4.4

UC, San Francisco 9.4 4.7 3.2

Mayo, Rochester MN 8.9 3.0 3.9

Source: Goodman, Health Affairs,March/April 2006.

Example 4: Are health outcomes related to physician labor inputs?

So what?

Would a physician surge cause any harm?

Where do more physicians go?

1979

1999

Source: Goodman. Health Affairs, 2004.

For every physician that settled in a low supply

region, 4 physicians settled in a high supply region.

High Physician Supply Regions:

• High bed capacity, medical admission rates.

• High physician visit rates.

• High intensity care at the end of life.

• High costs.

• Lower perceived access.

• No better patient satisfaction.

• Worse technical quality.

• Greater tendency for physicians to use aggressive instead of conservative treatment.

• Physicians perceive care to be less available, less able to provide quality care.

• No better and perhaps worse patient outcomes.Sirovich B, et al. Ann Int Med 2006.

Wennberg J. Ed. Dartmouth Atlas of Health Care. Various editions. 1996 - 2006.

Fisher E, et al. Ann Int Med 2003.Fisher E, at al. Health Affairs 2004.Fisher E, et al. Health Affairs 2005.Goodman D, et al. Health Affairs 2006.

Where would you invest $5 billion per annum of public money in the

health care system?

• Improvements in care systems in an effort to improve quality.• Rewarding health care systems for improved outcomes.• Implementation of the U.S. Preventive Services Task Force

recommendations.• Expanding insurance coverage to children (S-CHIP).• Health insurance for returning Iraq war vets who aren't covered at

their jobs.• Establishment of effective post-marketing surveillance system for

drugs / devices.• Increasing physician training rates?

The Center for the Evaluative Clinical SciencesDartmouth Medical School

• John Wennberg, MD MPH • Elliott Fisher, MD MPH• George Little, MD• Therese Stukel, PhD• Jonathan Skinner, PhD• Katherine Baiker, PhD• Julie Bynum, MD• Scott Shipman, MD MPH• Douglas Staiger, PhD• Amitabh Chandra, PhD• James Weinstein, MD MS• David Wennberg, MD MPH• Sally Sharp, SM• Stephanie Raymond• Phyllis Wright-Slaughter, MHA• Daniel Gottlieb, MS• Kristen Bronner, MA• Vin Fusca, MMS• Megan McAndrews, MBA, MS• David Bott, PhD• Stephen Mick, PhD (VCU) • Chiang-hua Chang, MS• Nancy Marth, MS• Jon Lurie, MD MS• Ken Schoendorf, MD MPH (CDC/NCHS)

• The Robert Wood Johnson Foundation

• Health Resources and Services Administration

• WellPoint Foundation

• Aetna Foundation

• United Health Foundation

• California HealthCare Foundation

• National Institute on Aging

Collaborators Support