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7th Annual Physician Workforce Research Conference
Physician Response to Economic Incentives
Adam Smith’s Invisible Handshake With
Hippocrates
D. Douglas Miller, MD, CM, MBAAAMC Robert G. Petersdorf Scholar
AAMC Petersdorf Project
Premise 1National and regional economies directly and indirectly affect medical student career decisions.
Corollary 1Significant economic downturns (i.e. recessions) create financial pressures that impair the physician workforce’s free market capacity to self-correct.
AAMC Petersdorf Project
Premise 2Resourcing of state/provincial health care costs is critical to public medical education expansion & workforce balance.
Corollary 2Public resource contraction impacts household finances, and medical student ‘consumer ’decisions tied to tuition price, personal debt & future income.
AAMC Petersdorf Project
Premise 3Publicly-financed national health care systems in which medical students clinically train affect their ultimate career decisions.
Corollary 3Different U.S. and Canadian health care delivery systems create different primary care workforces.
“The Great Recession”– Economic Ground Zero
The “Great Recession” of 2007-09
Impact Across the 49th ParallelUnited States Canada
GDP Nadir -6.8%
Stock Market Fall -52%
Unemployment 10.1%
CCI Nadir 25
Savings Rate 8%
-1.8%
-48%
8.3%
54
1%
USA Breaking From the Pack
USA
Canada
I. U.S. and Canadian Economies (1980-2010)For ~30 years, both national economies grew &
diversified to comparable degrees. After recessions, health care cost escalated
transiently then plateau’d; post-2000 increases as % of GDP were comparable (U.S.=+27.2%, Canada=+28.5%).
2007-09 “Great Recession” had a more severe impact on the U.S. economy, although ARRA permitted more U.S. personal savings and financial deleveraging.
2000-01 “Dot.com” recession did not impact Canadian CCI. 2007-09 recession reduced Canadian personal savings rates to all time lows.
National Health Care Policy Actions (1980-2010)TWO PATHWAYS TO UNIVERSALITY
• >10 U.S. federal health care policies (MCR Secondary Payer Act, MCR PPS, COBRA, EMTALA, MCR Catastrophic Coverage Act, MCR RBRVS, HIPAA, BBA, SCHIP, MCR Rx Drug Act, PSQIA, ARRA, CHIPRA, ACA)
• 1 Canadian federal health care policy (CHA), renewed by 2003 Ministers’ Health Care Accord
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
USA
Canada
Recessions
CHA
ACA
II. U.S. and Canadian Health Policy (1980-2010)>10-fold more U.S. federal health care policies enacted
to address costs/gaps/access before 2010 ACA ‘universality’.
2003 Canadian policy renewal of 1984 single-payer public insurance and federal funding commitments.
U.S. private sector co-insurance options and health insurance premiums grew incrementally from 1995-2003, achieving a ‘balanced’ market circa 2005.
Both countries face regional health & wealth disparities, but the U.S. has greater health care cost variability.
U.S. policy stakeholders & care delivery agents add complexity, threatening ACA implementation & system sustainability.
U.S. GQ Primary Care Choices (1978-2010)
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
0
0.1
0.2
0.3
0.4
0.5
0.6
FMIMPedsTotal PC
1978-1992 1998-2010
?
Primary Care Career ChoicesU.S. GQ (2001-2010)
Canada CGQ (2001-2010)
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
FMIMPedsPC Total
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
0.1
0.2
0.3
0.4
0.5
0.6
FMIMPedsPC Total
III. Graduate Profiles & Primary Care Career Choices (2001-2010)U.S. GQ Canada CGQ
Female = +2.7%; av. debt = +38%
After steady PC choice decline, sudden 2008-10 increase, mainly from internal medicine (IM)
Abrupt PC increases preceded both Dem. pro-universality policy reform efforts (Clinton 1990-93, Obama 2008-10); IM choices may reflect (mal-) adaptation to policy outcome uncertainties.
Female = +4.7%; av. debt = +32%
After stable PC choices, sudden 2009-10 increase, mainly from family medicine (FM)
Delayed (from 2003 policy renewal) 2009 FM increase tracked regional policy actions (i.e., a new North Ontario medical school, PC ‘teams’, better PC pay, etc.), and vested universal access to care role of FM.
U.S. v MA GQ Primary Care Choices
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Mass. PC TotalUSA PC Total
MA Primary Care Career Choices
% Annual Variability % PC Change Histogram
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
1
1.2
% GDP Change% PC Change
0.00
50.
01
0.01
50.
02
0.02
50.
03
0.03
50.
04
0.04
50.
050.
060.
070.
080.
09 0.1
0.2
0.3M
ore
0
1
2
3
4
5
6
7
8
9
1 2
Kurtosis = 7.5 Skewness = 2
IV. MA Policy Reform & MD Career ChoicePhase 1 (2005-07) & Phase 2 (2008-2010) MA health
care policy reform increased the insured population (%, #).
MA PC choices paralleled the U.S. trend of sharp 2005-07 declines, and abrupt 2008-10 increases.
After 2005, annual variability in PC choices was greater in MA v U.S. (43±35% v 22±28%; p<0.005), with year-to-year variability ≥20% in 5/6 years in MA.
Dual pressures of state and national policy reforms may contribute to greater PC choice volatility, and lower GQ satisfaction with non-clinical educational domains in MA.
Lagging & Leading Economic Indicators
Fisca
l Yea
r19
8219
8519
8819
9119
9419
9720
0020
0320
0620
090
0.02
0.04
0.06
0.08
0.1
0.12
0.14
Canada USA
Unemployment
1997-1 2001-3 2003-52004-112006-52007-112009-50
20
40
60
80
100
120
140
160
US CCICdn. CCI
Consumer Confidence Index
V. Career Choice Confidence
Occupational Alternatives Questionnaire (OAQ): fell significantly in the 2009-10 NRMP match
cycle; greater M declines were sustained into the 2010-11 cycle.
OAQ trended with lagging economic indicators (i.e., unemployment) > leading economic indicators (i.e., CCI)
U.S. Graduate Career Choice Confidence
OAQ v CCI TrendsGender OAQ Differences
2007 2008 2009 2010 20112.00
2.20
2.40
2.60
2.80
3.00
3.20
FM
2007
-1
2007
-6
2007
-11
2008
-4
2008
-9
2009
-2
2009
-7
2009
-12
2010
-5
2010
-10
2011
-30
0.5
1
1.5
2
2.5
3
3.5
US MS OAQMoving average (US MS OAQ)US CCI x0.025Moving average (US CCI x0.025)
V. Career Choice Confidence
19% of 2010-11 graduates answered “YES” to: “Did factors affecting the U.S. economy influence your specialty decision?”
“YES” respondents cited:emotions (i.e., fear, pessimism, uncertainty,
insecurity)mental accounting for future income (i.e.,
salary, reimbursement, debt repayment capacity).
Top 10 Themes for “Yes” Responses: Code Counts Yes
respondentsN = 564
No respondentsN= 1,314
salary 14% (77) 8% (99)
loan repayments 9% (49) 2% (28)
debt consideration 8% (46) 5% (73)
economy as a general consideration
6% (34) 1% (14)
loan size 5% (31) <1% (5)
future reimbursement
5% (28) 2% (32)
negative perceptions of primary care
5% (26) <1% (3)
health care reform 4% (24) <1% (12)
decided against lower paying specialties
4% (21) < 1% (3)
supply and demand 4% (20) < 1% (4)
Top 10 Themes for “No” Responses:Code Counts No respondents
N = 1,314Yes respondentsN = 564
happiness/enjoyment
15% (191) 1% (6)
chosen specialty interest
10% (137) 3% (17)
passion 9% (119) 1% (6)
salary 8% (99) 14% (77)
money not important
8% (99) 0% (0)
debt consideration 5% (73) 8% (46)
chose primary care 5% (64) 2% (9)
stability of medicine 4% (51) 2% (10)
good living 3% (35) <1% (5)
future reimbursement 2% (32) 5% (28)
confirmation 2% (32) <1% (2)
long-term view 2% (32) < 1% (2)
Medical Applicant Price Sensitivity
Total Applications Average Tuition & Fees
1996
1998
2000
2002
2004
2006
2008
2010
0
5000
10000
15000
20000
25000
30000
U.S. WOMENU.S. MENCanada WOMENCanada MEN
96 98 00 02 04 06 08 100.00
5000.00
10000.00
15000.00
20000.00
25000.00
30000.00
35000.00
40000.00
45000.00
50000.00
CanadaU.S. PrivateU.S. Public
Medical Applicant Price Sensitivity
U.S. Price Elasticity Canadian Price Elasticity
1996
1998
2000
2002
2004
2006
2008
2010
-3.00
-2.00
-1.00
0.00
1.00
2.00
3.00
US Women PrivateUS Women PublicUS Men PrivateUS Men Public
1996
1998
2000
2002
2004
2006
2008
2010
-7
-6
-5
-4
-3
-2
-1
0
1
2
Canada WomenCanada Men
Conclusions1. In a severe economic recession, free market career
choice tilts the physician workforce balance (i.e., PC versus specialists, and choices within PC).
2. Without government regulation &/or professional organization intervention, ‘bad economy’ career decisions reflect personal finances > public interests.
3. Health care policy fostering universal PC access &/or rewarding accountable care alters MS-4 career decisions: - in favor of perceived system needs (for FM in Canada),- in reaction to systemic uncertainties (to IM in U.S., MA).
Conclusions (cont’d.)4. 19% of 2010-11 graduates cited economic factors
affecting their specialty decisions, with M>F career choice confidence erosion since 2009-10.
5. Medical school applicant elasticity to higher tuition:- ‘bearish’ demand occurred in U.S. & Canadian
men from 2000-2002 - ‘bullish’ applicant supply occurred in Canada & the U.S. from 2007-09.
Thanks to all my EDI, AAMC and AFMC colleagues
