CS

WcARtUomsc

C

1

2

3

4

la

aooc(iep

iiati

*

*JD4BE

R

1

2

3

4

5

6

7

8

9

R

Tgws2“cedsnto

ucwostcMct4

trwssToa

838 Correspondence JACC Vol. 55, No. 8, 2010February 23, 2010:836–9

ardiology Workforce Crisishortage or Surplus?

hile providing a detailed overview of the demographics of theardiovascular (CV) specialist community in the U.S. today, themerican College of Cardiology (ACC) Workforce Task Forceeport relies on limited evidence to support its conclusion that

here is a critical and growing shortage of CV specialists in the.S. (1). In addition, the report did not address dissenting expertpinion and published data indicating that, to the contrary, thereay exist now a surplus of physician specialists (including CV

pecialists) and that this surplus is a major driver of excessive healthare spending in the U.S. (2,3).

According to reports from the Dartmouth Atlas of Healthare (4 – 6):

. Specialist physicians tend to live and work in areas where theywant to live and near where they trained, not in areas of greatestneed or highest prevalence of disease.

. Concentration of specialist physicians varies widely (as much as300%) across the U.S.

. Regions of the country with the highest specialist physicianconcentration have higher health care costs, yet patients have nobetter health care outcomes than those in regions of lowestconcentration.

. Patients living in the regions of lowest specialty physicianconcentration self-report the same high level of satisfactionwith access to care as patients living in the regions of highestconcentration.

These data make a reasonable case that the U.S. would haveower costs without significant impact on quality of care or patientccess with a lower overall concentration of specialist physicians.

The ACC Workforce Report also did not address concerns thatlarge proportion of care provided in the U.S. today represents

veruse, and this excess care provides no added value to the patientr to the health system (7). The ACC has acknowledged thisoncern and has supported efforts to reduce overuse of CV care8,9). Yet the ACC Workforce Report does not factor in thempact of this reduction into its work force estimation. If thesefforts are even partially achieved, U.S. cardiologists may have lessroductive work to do, rather than more, in the years ahead.

There has been no public outcry indicating a CV workforce crisisn the U.S. Unsustainable growth in health care costs and healthnsurance premiums are the critical concerns of the public. Beforedvocating growth in the number of CV specialists in the U.S.,he ACC should consider all the evidence in this field and thempact of this growth on the national crisis in health care costs.

Joseph E. Marine, MD

Department of Medicine/Cardiologyohns Hopkins Universityivision of Cardiology, A-1 East

940 Eastern Avenuealtimore, Maryland 21224-mail: jmarine2@jhmi.edu

doi:10.1016/j.jacc.2009.11.030 u

EFERENCES

. Rodgers GP, Conti JB, Feinstein JA, et al. ACC 2009 survey resultsand recommendations: addressing the cardiology workforce crisis: areport of the ACC Board of Trustees Workforce Task Force. J Am CollCardiol 2009;54:1195–208.

. Starfield B, Shi L, Grover A, Mackinco J. The effects of specialistsupply on populations’ health: assessing the evidence. Health Affairs2005;W5:97–107.

. Goodman DC. The physician workforce crisis: where is the evidence?Health Affairs 2005;W5:108–10.

. Fisher ES, Wennberg DE, Stukel TA, et al. The implications ofregional variations in Medicare spending. Part 1: the content, quality,and accessibility of care. Ann Intern Med 2003;138:273–87.

. Goodman DC, Fisher ES. Physician workforce crisis? Wrong diagno-sis, wrong prescription. N Engl J Med 2008;358:1658–61.

. Goodman DC. Linking workforce policy to healthcare reform. Invitedtestimony, U.S. Senate Committee on Finance, March 12, 2009. Availableat: http://www.dartmouthatlas.org/press/Goodman_Sen_Fin_2009.pdf. Accessed September 21, 2009.

. PricewaterhouseCooper’s Health Research Institute. The price of ex-cess: identifying waste in healthcare spending. Available at: http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml.Accessed September 21, 2009.

. Dove JT, Weaver WD, Lewin J. Professional accountability in healthsystem reform. J Am Coll Cardiol 2009;54:499–501.

. Weaver WD. President’s page: carrying our message on quality andreform forward. J Am Coll Cardiol 2009;53:859–67.

eply

he American College of Cardiology (ACC) Workforce Work-roup recently published its study of the cardiovascular (CV)orkforce (1) and concluded that there is currently a significant

hortage of cardiologists that is projected to worsen over the nextdecades. Our workgroup did not attempt to determine the

right” number of cardiologists because this approach is tooonceptual and dependent on assumptions that it may have littlenduring applicability to the real situation. Notably, Weiner (2)etermined that the health care system would have far too manypecialists by 2000, but based his projections on a health mainte-ance organization staffing model that did not ultimately becomehe standard for the U.S. Many others (3–5) recently found thepposite, that we have a substantial shortage of specialists (refs).

Our workgroup chose to determine the demand for cardiologistssing a market-based approach. We surveyed the employers ofardiologists. Private and academic practices are intimately in touchith the demands for their services in their regions and the limitationsf their practices to deliver these services. The ACC and Medaxiomurveyed these employers in 2007 and received responses from 15% ofhe workforce. Our metric was open positions for cardiologists. Ouronsultants at the Lewin Group and the Association of American

edical Colleges (AAMC) further analyzed Medicare and commer-ial insurance data to assess the demand for CV services trends. Fromhe standpoint of the marketplace, there is a significant shortage of,286 cardiologists.

Certain demand drivers such as the aging of the baby boomers,he epidemic of obesity, expansion of insurance coverage undereform, and technological advances suggest that these demandsill increases over the next decade. Dr. Marine points out recent

tudies (the Dartmouth Atlas of Health Care in particular) thatuggest overuse of CV services in certain regions of the U.S. (6).he ACC strongly supports appropriate use and a focus on qualityf care. Inasmuch as the ACC and health care reform can influenceppropriate use, we may see some decrease in demand. The

ltimate effect of all these drivers can only be viewed in retrospect,

ap

i(wWmbwccw

*

*1AE

P

R

1

2

3

4

5

6

839JACC Vol. 55, No. 8, 2010 CorrespondenceFebruary 23, 2010:836–9

nd toward this end, the ACC Workgroup intends to surveyractices on an ongoing basis.

The most alarming result of our study was the age distributionn the current workforce. Forty-three percent of our cardiologists10,261 of 23,662) are 55 years or older. This is the age when thoseho have worked hard for many years start to consider retirement.ith financial portfolios recovering from the 2008 economiceltdown and the present threat of substantial changes in reim-

ursement and onerous regulation, our greater concern is whethere will be able to adjust to the early retirement of several thousand

ardiologists in a system that is annually replenished by 750 newardiologists. Even in a scenario of optimal use of CV services thisould represent a critical shortage that everyone would recognize.

George Rodgers, MD

Biophysical Corporation0801-2 North MoPac Expressway, Suite 140ustin, Texas 78759-mail: grodgers@biophysicalcorp.com

doi:10.1016/j.jacc.2009.11.031

lease note: Dr. Rodgers is the Chair of the ACC Workforce Task Force.

EFERENCES

. Rodgers GP, Conti JB, Feinstein JA, et al. ACC 2009 survey resultsand recommendations addressing the cardiology workforce crisis: areport of the ACC Board of Trustees Workforce Taskforce. J Am CollCardiol 2009;54:1195–208.

. Weiner JP. Forecasting the effect of health reform on U.S. physicianworkforce requirements. Evidence for the HMO staffing patterns.JAMA 1994;272:222–30

. Cooper RA, Getzer EG. The coming physician shortage. HealthAffairs 2002;21:296–9.

. Bureau of Health Professions, Physician Supply and Demand Projec-tions to 2020. U.S. Department of Health and Human Services,October 2006. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/physicianworkforce.htm. Accessed

. Council on Graduate Medical Education, Reassessing Physician Work-force Policy Guidelines for the U.S. 2000–2020, Washington, DC:U.S. Department of Health and Human Services, 2005.

. Fisher ES, Wennberg DE, Stukel TA, et al. The implications of

regional variations in Medicare spending. Part 1: the content, quality,and accessibility of care. Ann Intern Med 2003;138:273–87.