POTENTIAL SOLUTIONS for the EVOLVING PHYSICIAN SHORTAGE

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


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


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


Black Bachelor'sDegrees


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.

Documents

POTENTIAL SOLUTIONS for the EVOLVING PHYSICIAN SHORTAGE