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Physician Supply and Distribution
At first glance, physician distribution may seem like a boring topic.
Who cares what kinds of physicians there are, where they live, and what
type of practice they have? Yet these same facts drive national policy and
will drive the health care market during your years of practice as a
physician.
- What were earlier
federal policies?
- What were they supposed
to correct?
- What has happened since
then?
- What are our problems
now?
- What role do HMOs
play?
- How does this affect
medical students and physicians?
Within the past year, students came face to face with the relevance of
health care policy as Congress debated issues such as capping medical
residencies to 110% of U.S. medical school graduates and placing
restrictions on residency programs to promote equal numbers of generalist
and specialist physicians. These proposals can seem threatening, as our
current system allocates the amount of first year residency slots to equal
140% of U.S. medical school graduates, and currently, medical students
choose to enter specialty practice three times more frequently than they
enter generalist practice. The majority of medical students, physicians
and members of the community at large were initially caught unaware by
these proposals. Where did they come from? Why does the government have
the right to control physician supply and distribution? (COGME)
Yet, with a second look, medical students can see that we have entered
medical school during a time of evaluation, when the medical community is
examining the successes and failures of earlier policies and is working to
change and improve national policy so that health care professionals can
provide high-quality health care to everyone in the country. By using this
module, you can educate medical students about our practice environment:
physician distribution, the effect of HMOs, and the changing proportions
of generalists and specialists.
STUDENT ORGANIZERS GUIDE
- Organize a brown bag lunch or afternoon discussion.
- In this module, you will find materials for students: a fact sheet
about physician supply and distribution and an article, "The Third
Report of the Council on Graduate Medical Education." This report was
written in 1992 by a group of physicians and health care providers
commissioned by the federal government to examine the data on the
nation's supply and distribution of physicians and medical personnel.
COGME's Third Report has sparked examination of the current system and
has become quite influential in determining national health policy.
- Invite a physician to come speak about this issue. Invite someone
interested in policy and/or active at an affiliated School of Public
Policy. Or invite a generalist physician who has worked in an
underserved area, or who works in an HMO, to tell you about their
experiences.
As Congress debated capping residency positions to 110% of U.S. medical
school graduates and equalizing the number of generalist and specialist
physicians, it became increasingly apparent that we, as medical students,
should have a preliminary understanding of the policy involving the
medical system around us. Even though health care reform did not pass the
103rd Congress, our generation of medical students is still entering a
changing medical system, which will continue to be molded by market forces
and federal/state policy, ideally improving access to, and cost and
quality of health care for all Americans. What drives these policies? How
can our medical education system provide the physicians needed in our
country? How will we be affected?
When Did All This Start?
In
the 1960s, the medical community and the federal government decided to
work together in order to provide adequate medical care to the citizens of
the United States. Reports such as the 1966 Millis report called for the
country to provide equal access to primary health care. "Medical schools
and teaching hospitals should prepare many more physicians than now exist
who will have the desire and the qualifications to render comprehensive,
continuing health services, including preventive measures, early
diagnosis, rehabilitation, and supportive therapy, as well as diagnosis
and treatment of acute or episodic disease states." And so, as the
government enacted plans such as Medicare and Medicaid, it simultaneously
provided incentives to increase the number of physicians in the hopes of
reaching a growing population and providing medical coverage to an
increasing number of medically underserved areas. These incentives were
given to medical schools to increase their number of medical students, and
to hospitals to subsidize residency training.
Since 1960, the number of allopathic (MD) and osteopathic (DO) medical
schools has increased from 86 to 141, and the total enrollment has
increased from 30,000 students in 1960 to over 70,000 in 1994.
(COGME)
Presently, the federal government pays hospitals approximately $70,000
per year per resident that they train (average resident's stipend:
$31-38,000). The bulk of federal money, $5.5 billion, is paid by Medicare
via Direct Medical Education Funds ($1.5 billion) that are paid per
resident, and Indirect Medical Funds ($3.33 billion), which supplement
payment for patient care. In addition, the Department of Veterans Affairs
pays $400 million and the Department of Defense pays $200 million.
(COGME)
The number of residency positions has
been growing rapidly.
Currently, there are 24,000 first-year
residency slots, which are filled by 18,000 allopathic and osteopathic
U.S. graduates and by 6,000 International Medical Graduates (IMGs).
Currently in the U.S., the number and type of residency positions are
determined primarily by the ability of teaching institutions to develop
programs of acceptable quality. Because residents provide service for the
hospital and the hospitals receive $70,000 per resident, it is not
surprising that the number of residents trained in the country is
growing.
Since 1990, 1,500 new positions have been
added.
As a point of comparison, in Great Britain, the
government finances all residency slots and controls the number of
positions by specialty. In Canada, the number of positions funded by the
provincial ministries of health care is determined in negotiations between
the medical schools, provincial governments and physician
associations.
While increases in physician numbers during the 1960s, 1970s and 1980s
were due to more U.S. medical students, recent increases relate more to
the number of IMGs. Since the mid-1980s, the number of first-year IMG
residents has increased from 12,000 in 1988 to 19,000 in 1992, an increase
from 15% to 22% of all residents. In New Jersey and New York, IMGs
currently make up 58% and 42%, respectively, of all medical residents.
(Shroeder, S.A. The Latest Forecast: Managed Care Collides with
Physician Supply. JAMA, July 20, 1994. Vol. 272(3):
239-240.)
IMGs tend to remain in generalist medical specialties at the same rate
as U.S. graduates. While significantly more IMGs enter internal medicine
and pediatrics residencies, they then subspecialize at a higher rate than
U.S. medical graduates.
How has this policy affected the number
of physicians in the United States?
Between 1960 and 1988,
the number of physicians in the United States more than doubled from
250,000 to 650,000. Initially, it was hoped that increasing the total
number of physicians in the United States would increase the number of
practicing generalists who would provide primary care to the majority of
Americans, particularly by serving in underserved areas.
Yet, while the total number of physicians has doubled, the proportions
of generalist and specialist MD physicians have changed from 50%
generalists and 50% specialists in 1961 to the present proportions of 28%
generalists and 72% specialists. When ob/gyn and emergency medicine
physicians are included in the generalist definition, the ratio is still
32% primary care to 68% specialists. This decline in the percentage of
generalists is likely to continue, as the amount of allopathic medical
students expressing interest in generalist medicine in 1991 and 1992 fell
to 17% of U.S. medical graduates. (COGME)
Due to the increased number of physicians, primary care access has
improved in some areas of the country. According to the Government
Accounting Office (1994), the ratio of primary care physicians in the most
densely populated urban areas improved from one primary care physician per
1,265 residents in 1975 to one per 879 in 1990. In rural areas the ratio
improved from one primary care physician per 2,536 people in 1975 to one
per 1,872 in 1990.
However, these improvements have surprisingly not affected the most
underserved areas of the country, the very areas that the initial
legislation was designed to benefit. The number of Health Profession
Shortage Areas (HPSAs) - defined as counties/communities with more than
3,500 people per primary care physician - has increased slightly to more
than 2,000 areas.
During the 1980s and 1990s, the number of full-time physicians needed
to serve these areas has actually increased slightly from 4,496 in 1984 to
4,533 physicians in 1992.
Why are there more specialists than
generalists?
Some of the factors leading to the increased
number of specialists include: higher financial compensation for
specialists, decreased prestige for generalists, medical training based in
tertiary care centers, decreased exposure to generalist role models, and
(for physicians practicing in rural and underserved areas) relative
isolation from technology and peer support.
A study by Schroeder and Showstack described how primary care
internists, while limiting charges to those allowable under Medicaid,
could triple their annual income by providing common laboratory procedures
in the office; although they would not be able to treat as many patients.
(Schroeder S.A., Showstack J.A. Financial Incentives to Perform
Medical Procedures and Laboratory Tests: Illustrative Models of Office
Practice.)
Hsiao and Stason demonstrate that a surgeon receives three to seven
times more money per hour for time spent in the operating room than for
time spent with patients or in consultation. (Hsiao W.C., Statson, W.B.
Towards Developing a Relative Value Scale for Medical and Surgical
Services. Health Care Financing Review, Fall 1979: 23-28.)
In addition, students who train in tertiary care settings are more
likely to remain in those settings. Model training programs, such as some
based in Minnesota, Pennsylvania and Iowa, demonstrate that medical
students who train in rural areas are more likely to practice in those
areas. (COGME)
Does this affect the cost and quality of
medical care?
While it has generated a great deal of
important research over the past 20 years, our country's
specialist-centered system has also contributed to the high cost of
medical care, the discontinuity of individual care and the shortage of
physicians in rural areas.
For a specialist-centered model of care to flourish, specialists must
work in metropolitan areas where they have a large patient base. As a
result, both the number of specialists and the total number of doctors
concentrated in metropolitan areas have continued to grow.
Care provided by specialists is more expensive than similar care
provided by generalists. A study conducted by Welch and Miller et al.
concluded that geographic distributions in physician costs did not relate
to the percentage of inpatients vs. outpatients, the number of diagnostic
studies conducted, or the severity of patient illness; instead, physician
costs related to the percentage of specialists vs. generalists in a given
area. (Welch, W.P., Miller, M.E., Welch, H.G., et al. Geographic
Variation in Expenditures for Physicians' Services in the United States.
NEJM, 1993; 328: 21-27.)
Residents of low-income areas in Washington, D.C., who often do not
have access to primary care physicians, are hospitalized three times more
frequently than people in high-income communities for asthma, diabetes,
high blood pressure and many other conditions that can be treated with
routine medical care (Washington Post, August 1, 1994.)
How do HMOs affect this
issue?
Enrollment in managed care plans has increased from
12.5 million people in 1983, to 45 million in 1993. In 1994, HMOs served
16% of the population. HMO systems tend to utilize an increased number of
generalist physicians and a decreased number of specialists. Therefore, as
managed care grows, our country will likely be faced with a specialist
surplus and a generalist shortfall.
Anecdotal data from large HMOs indicate that generalist physicians are
already receiving higher salaries and that specialists are finding
significantly less demand for their services. Specialists who were not
quick to join HMOs - often those specialists with the strongest private
practices - are now having difficulty finding opportunities to join.
According to the Bureau of Health Professions, in a managed
care-dominated health care system utilizing 137 physicians per 100,000
population, there will be a shortage by the year 2000 (of 35,000
generalist physicians, and a surplus of 115, 000 specialist physicians) if
present patterns of specialty choice continue.
According to Weiner in a study examining HMO staffing patterns, when
our medical system develops to the point where 40% to 65% of Americans
receive care from managed care networks (utilizing 120 physicians per
100,000 population), there will be an overall surplus of 165,000
physicians; the requirements and supply of primary care physicians will be
in relative balance, and the supply of specialists will outstrip
requirements by more than 60%.
If managed care is implemented for everyone in the nation, it is likely
that a 65% generalist to 35% specialist ratio will be necessary to provide
adequate medical care.
(Weiner, J.P. Forecasting the Effects of Health Reform
on U.S. Physician Workforce Requirements: Evidence from HMO Staffing
Patterns. JAMA 1994; 272:
222-230.)
Suggested Solutions
It has
become clear, as many groups have researched the nation's health care work
force, that our country does not have a plan to optimize the number of
physicians and their areas of training so that we can meet our health care
needs. There are a number of solutions under consideration:
- Increase generalist physicians' salaries, particularly by narrowing
the generalist-to-specialist reimbursement differential. In this system,
physicians would receive less compensation for procedures and more
compensation for diagnosis and patient education.
- Increase the prestige of generalist physicians by instituting
departments of Family Medicine at all medical schools, along with
increasing funding for primary care research and providing community
physicians with admitting privileges at local hospitals.
- Limit the number of U.S. residency positions to 110% of the number
of U.S. medical school graduates. (All medical groups recommend keeping
the number of residency slots above the number of graduating U.S.
medical students in order to fulfill a long-standing commitment to train
foreign medical graduates.)
- Compose the U.S. residency positions so that an even number of
generalists and specialists are produced.
- Change Medicaid funding of residencies to support community-based
training.
- Create an all-payer pool so that all medical providers pay equally
for medical training and there is not an economic incentive to utilize
non-teaching facilities.
How can students get
involved?
If students are concerned about the supply or
distribution of physicians, or have opinions about the suggested solutions
to these problems, they can:
Write to their state or national representatives or senators, or
organize a letter-writing campaign. This is an important time to let
legislators know the opinions of tomorrow's physicians, particularly as
legislators debate issues such as the future of the National Health
Service Corps. AMSA has a full-time lobbyist who works to represent
medical student opinions. For more information about legislative
activism, call AMSA's Legislative Affairs Director at (703)620-6600 ext.
211. The current LAD will send you a packet of information with sample
letters and suggestions on how to lobby legislators.
For students interested in health care policy, the AMSA
Resource Center has an excellent guide to Health Policy Fellowships. The
guide contains national- and state-based fellowships, as well as summer
and rotational opportunities. To receive this guide, call AMSA at (703)
620-6600, ext. 217.
Questions to Think About
- Why, if there are so many physicians, are there so many more
specialists than generalists?
- What, if anything, could have been done differently to prevent this?
- How should our country work to get physicians into underserved
areas?
- What would influence individual students to dedicate part or all of
their career to an underserved area?
- Is it the responsibility of the medical profession to guarantee that
all Americans have access to a physician (i.e. geographic access)?
Should this be a goal that medical schools and medical organizations
work to achieve?
- Should medical education be a private/public partnership (i.e.
funded by the medical student, the medical institution and the federal
government)?
- Is medicine inherently different from other professions and does it
therefore deserve this funding?
- What obligations do future physicians have to their medical
institutions and the federal government in exchange for a subsidized
education?
- Would it be better if the federal government had no role?
- Would it be better if the government paid the individual student's
share (so that medical school was free) in exchange for years of
service?
- Would a change in this system lead to improved physician
distribution?
- Should future physicians and the public be better educated about the
public-private partnership that exists today? How?
References
- Much of the information in this Project-in-a-Box comes
from the following COGME sources:
- Council on Graduate Medical Education Third Report,
"Improving Access to Health Care Through Physician Workforce Reform,"
U.S. Department of Health and Human Services; Washington, D.C.,
1992.
- Council on Graduate Medical Education Fourth Report.
"Recommendations to Improve Access to Health Care Through Physician
Workforce Reform," U.S. Department of Health and Human Services;
Washington, D.C., 1994.
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