Trends in Physician Supply in North Carolina December, 2005 Thomas C. Ricketts, Ph.D. Erin Fraher, MPP; Katie Gaul, MA; Jennifer King, Hazel Hadley University

Trends inTrends inPhysician SupplyPhysician Supplyin North Carolinain North Carolina

Trends inTrends inPhysician SupplyPhysician Supplyin North Carolinain North Carolina

1998

1999

2000

2001

2002

Hospital Setting

Clinics

050

100

150

200

250

300

350

December, 2005

Thomas C. Ricketts, Ph.D.Thomas C. Ricketts, Ph.D.Erin Fraher, MPP; Katie Gaul, MA; Erin Fraher, MPP; Katie Gaul, MA;

Jennifer King, Hazel HadleyJennifer King, Hazel Hadley

University of North Carolina at Chapel HillUniversity of North Carolina at Chapel Hill

Thomas C. Ricketts, Ph.D.Thomas C. Ricketts, Ph.D.Erin Fraher, MPP; Katie Gaul, MA; Erin Fraher, MPP; Katie Gaul, MA;

Jennifer King, Hazel HadleyJennifer King, Hazel Hadley

University of North Carolina at Chapel HillUniversity of North Carolina at Chapel Hill

Goals for the PresentationGoals for the Presentation

Highlight emerging trends in the supply of Highlight emerging trends in the supply of physicians, nurse practitioners, and physicians, nurse practitioners, and physician assistants in the US and NC.physician assistants in the US and NC.

Closely examine the characteristics of Closely examine the characteristics of physicians who are new to practice in NC.physicians who are new to practice in NC.

Estimate the future supply of physicians Estimate the future supply of physicians for the NC under optional scenarios.for the NC under optional scenarios.

Review some medical workforce policy Review some medical workforce policy options in other states.options in other states.

Main Message: The Supply of Main Message: The Supply of Physicians Is Growing Physicians Is Growing Slower than Slower than

PopulationPopulationPopulation growth for 2002-2005 Population growth for 2002-2005

exceeds physician supply growth.exceeds physician supply growth.National estimates project an National estimates project an

emerging shortage.emerging shortage.NC reflects these trends.NC reflects these trends.This may cause access problems in This may cause access problems in

North Carolina in the near future.North Carolina in the near future.

NC Population Has GrownNC Population Has Grownand slightly faster than the USand slightly faster than the US

1

1.05

1.1

1.15

1.2

1.25

1993

1994

1995

1996 19

9719

9819

9920

0020

0120

0220

0320

04

Year

Rela

tive

gro

wth

rate

North CarolinaUnited States

Source: US Census Bureau, NC State DemographerPopworksheet.xls

North Carolina 11th inNorth Carolina 11th inPopulation total,Population total,

9th in growth rate (4 years)9th in growth rate (4 years)

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Perc

en

t G

row

th

NC Primary Care MDs

NC Population

US Population

NC Total MDs

MD Growth Has Slowed to below MD Growth Has Slowed to below Population GrowthPopulation Growth

National ContextNational Context

Recognition of potential shortage by Recognition of potential shortage by national groups:national groups:American Association of Medical Colleges

(AAMC) reversed position in 2005 to say there is a shortage

Council on Graduate Medical Education reversed position in 2004 to say there may be a shortage coming

Family Physicians (AAFP) debating the issue

National ContextNational Context

Very slow Allopathic medical school growthVery slow Allopathic medical school growth Florida State only new allopathic school Others considered in TX, AZ, FL

Growth in small Osteopathic SchoolsGrowth in small Osteopathic Schools 2 new schools in Florida 2004-5

Lake Erie, 300 students in its 2Lake Erie, 300 students in its 2ndnd year year Northern Florida announces plansNorthern Florida announces plans

Nevada branch of Touro (CA) Osteopathic Medical School Philadelphia College of Osteopathic Medicine in Atlanta opened 2005

Kentucky (Pikeville School) opens in a consortium Virginia School (Edward Via) associated with Virginia

Tech Opens 2005.

Doctors are Trained in Two StepsDoctors are Trained in Two Steps

75% of US Doctor Supply comes from US 75% of US Doctor Supply comes from US Medical Schools via US ResidencyMedical Schools via US Residency

25% comes from Foreign Medical Schools, 25% comes from Foreign Medical Schools, via US Residenciesvia US Residencies

Medical School(4 years)

Residency(3-7 years)

US Medical Student Enrollment

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

1994-1995

1995-1996

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

2004-2005

Medical Students

Source: Barzansky B, Jonas HS, Etzel SI. JAMA, September 1, 282(9): 840-846; JAMA, September 3, 290(9): 1190-1196.; JAMA, September 7, 294(9): 1068-1074.

US Resident Physicians, 1994-2003

-

20,000

40,000

60,000

80,000

100,000

120,000

1994-1995

1995-1996

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

Total No. of Residents

USMGs

IMGs

DOs

Canadian

Unknown

General PictureGeneral Picture

An emerging shortage?An emerging shortage?

A Growth trend that is slowingA Growth trend that is slowing

Medical School and ResidencyMedical School and ResidencyNumbers “Flat” Numbers “Flat”

…………

What is happening in North What is happening in North Carolina?Carolina?

Pathways into Practice North Pathways into Practice North CarolinaCarolina

From Medical SchoolsFrom Medical SchoolsIn North CarolinaOther US and Canadian SchoolsInternational Medical Schools

From Residency ProgramsFrom Residency ProgramsIn North CarolinaIn other US states and Canada

In-migration from other StatesIn-migration from other States

Newly Licensed Patient Care Newly Licensed Patient Care Physicians in NC 1998-2004Physicians in NC 1998-2004

0

100

200

300

400

500

600

700

1998 1999 2000 2001 2002 2003 2004

Num

ber

of M

Ds Primary Care

Emergency Medicine

Surgery

Radiology

Psychiatry

Anesthesiology

Other

Source: NC Health Professions Data System, Sheps Center from dataProvided by the North Carolina Medical Board

Newly Licensed Patient Care Newly Licensed Patient Care Primary CarePrimary Care Physicians in North Physicians in North

CarolinaCarolina

0

50

100

150

200

250

300

1998 1999 2000 2001 2002 2003 2004

Num

ber

of M

Ds Internal Medicine

Family PracticeGeneral PracticeOB/GYNPediatrics


Newly Licensed Physicians Newly Licensed Physicians were….were….

More likely to be femaleMore likely to be female34% of new licensees are female vs. 25% of all

current, active NC physicians.More likely to be minorityMore likely to be minority

26% of new licensees are minority vs. 18% of all physicians.

YoungerYoungerAverage age of new licensees is 38.5 years vs.

46.4 years for all physicians.

Average Age of All and New Average Age of All and New Physicians Increasing SlowlyPhysicians Increasing Slowly

45.4 45.3 45.6 45.6 45.7 45.98 46.4

37.738.5

34.9 34.9 35.4 35.2 35.5

30

32

34

36

38

40

42

44

46

48

1998 1999 2000 2001 2002 2003 2004

Mea

n A

ge

All MDsNew MDs


Age-Gender Pyramid, PhysiciansNorth Carolina, 1980

400 350 300 250 200 150 100 50 0 50 100

Under 30313335373941434547495153

55575961636567697173757779

Over 80

Ag

e

Number of Physicians

Female

Male

Note: There w ere three physicians w ith missing age.

Figures include active, instate, nonfederal, non-resident-in-training physicians licensed in North Carolina as of October 31, 1980.Source: North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, with data derived from the North Carolina Medical Board, 1980.


450 400 350 300 250 200 150 100 50 0 50 100 150

Under 30313335373941

434547495153

55575961636567

697173757779

Over 80

Ag

e


Female

Male



550 500 450 400 350 300 250 200 150 100 50 0 50 100 150 200 250

Under 30

32

35

38

41

44

47

50

53

56

59

62

65

68

71

74

77

80

Ag

e


Female

Male

Note: There w ere three physicians w ith missing age.



550 500 450 400 350 300 250 200 150 100 50 0 50 100 150 200 250 300

Under 303133353739414345

474951535557596163

6567697173757779

Over 80

Ag

e


Female

Male


Gender Converging Slowly forGender Converging Slowly forNew MDsNew MDs

0100200300400500600700800900

1000

Num

ber

of M

Ds

1998 1999 2000 2001 2002 2003 2004

MaleFemale


Many, but Not Most New Patient Many, but Not Most New Patient Care MDs Go to NC Medical Care MDs Go to NC Medical

Schools Schools

8457 40 49

659

87

0

100

200

300

400

500

600

700

Medical School

UNC-CHBowman GrayDukeECUOther US

International

Majority of New Patient Care MDs Majority of New Patient Care MDs Do Residency in NCDo Residency in NC

0

100

200

300

400

500

600

Residency

NCOther US

InternationalUnknown

Osteopaths, relatively few, but Osteopaths, relatively few, but growing fast in numbersgrowing fast in numbers

0

50

100

150

200

250

300

350

400

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Nu

mb

er

of

DO

s

379 practicing in NC2.2% of Total Physician Supply

Growth rate of >10% per year

Trends in Physicians Delivering Trends in Physicians Delivering BabiesBabies

20002000 20012001 20022002 20032003 20042004

OBGsOBGs 919919 937937 954954 960960 981981

OBGs OBGs DeliveringDelivering

651651 701701 742742 750750 748748

% OBGs% OBGs 70.8%70.8% 74.8%74.8% 77.8%77.8% 78.1%78.1% 76.2%76.2%

FPsFPs 2,1732,173 2,2242,224 2,2932,293 2,3272,327 2,0402,040

FPs FPs DeliveringDelivering 212212 227227 228228 232232 205205

% FPs% FPs 9.8%9.8% 10.2%10.2% 9.9%9.9% 9.9%9.9% 10%10%

Delivery DynamicsDelivery Dynamics

Of the 101 physicians who stopped Of the 101 physicians who stopped providing obstetric deliveries providing obstetric deliveries between 2003 and 2004, 56 (56%) between 2003 and 2004, 56 (56%) were Family Docs. were Family Docs.

This is a disproportionate share This is a disproportionate share since family docs are just 13% of since family docs are just 13% of total physicians and 10% of total physicians and 10% of physicians delivering babies.physicians delivering babies.

IMGS—slight Increase;IMGS—slight Increase;NC IMGs Stable in Recent Years.NC IMGs Stable in Recent Years.

165 153 143 172 164 1630%

10%20%30%40%50%60%70%80%90%

100%

Perc

ent

of

New

MD

s

1997 1998 1999 2000 2001 2003

NC MGsUS/CDN MGsIMGs

Source: NC Health Professions Data System, Sheps Center.As reported on NC Medical Board license renewal and registration

NC TOTAL IMG = 13%NC TOTAL IMG = 13%US Avg = 24%US Avg = 24%

Components of Change, 2001-4Components of Change, 2001-4

New to file1,681

(status change 480newly licensed 1201)

2001 Supply16,392

Left File1,304

2002 total16,769

Net gain 377

New to file1,563


2002 Supply16,769

Left File1,242

2003 total17,090

Net gain 384


New to file1,413


2003 Supply17,090

Left File1,163

2003 total17,340

Net gain 250

What do we know about those who What do we know about those who left North Carolina or Practice?left North Carolina or Practice?

Between 2002 and 2003Between 2002 and 2003 143 physicians retired from practice. Average retirement

age was 66 years of age. 90% of retiring physicians were men. Only 2% did obstetric

deliveries. 303 physicians moved out of state but maintained an active

license 138 went inactive 658 dropped out of physician file (presumably moved)

51% of the 138 physicians who went inactive were 51% of the 138 physicians who went inactive were women. The average age of inactive females was 42 women. The average age of inactive females was 42 compared to 59 for inactive males.compared to 59 for inactive males.

Dynamics and ChangeDynamics and Change

The supply is dynamic with up to 20% of The supply is dynamic with up to 20% of all physicians moving either into or out of all physicians moving either into or out of active practice in NC.active practice in NC.

Many physicians move into and out of Many physicians move into and out of active practice during their careers.active practice during their careers.

The “net” supply is a “snapshot” of The “net” supply is a “snapshot” of changechange

There are other practitioners who can do There are other practitioners who can do what doctors do what doctors do —Nurse Practitioners —Nurse Practitioners and Physician Assistantsand Physician Assistants

Cumulative Growth of Nurse Cumulative Growth of Nurse Practitioners, Physician Assistants and Practitioners, Physician Assistants and Physicians, North Carolina, 1990-2004Physicians, North Carolina, 1990-2004

Cumulative rate of growth since 1990

231%

26.3

0

50

100

150

200

250

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

% r

ate

of

gro

wth

(cu

mu

lati

ve)

sin

ce

1990

Nurse Practitioners

Physician Assistants

Physicians

140%

QuestionsQuestions

Do NPs and PAs fill the gap left by Do NPs and PAs fill the gap left by the slowdown in physician growth?the slowdown in physician growth?

Do NPs and PAs expand demand for Do NPs and PAs expand demand for physician services?physician services?

Do NPs and Pas meet different Do NPs and Pas meet different patient care needs than physicians?patient care needs than physicians?

The Geography of Physician The Geography of Physician Supply in NCSupply in NC

Very uneven distribution of MDs in Very uneven distribution of MDs in North CarolinaNorth Carolina

Selected areas have recognized Selected areas have recognized “shortages” designated by the “shortages” designated by the federal government as Primary care federal government as Primary care Health Professional Shortage Areas Health Professional Shortage Areas (HPSAs)(HPSAs)

Primary Care Physicians per 10,000 Population*(# of Counties)

9.17 to 33.12 (19)7.41 to 9.16 (20)5.48 to 7.40 (20)4.28 to 5.47 (20)1.69 to 4.27 (21)

Primary Care Physicians per 10,000 PopulationNorth Carolina, 2004

AHEC Region Boundary

Source: North Carolina Health Professions Data System, with data derived from the North Carolina Medical Board, 2004.Produced by: North Carolina Health Professions Data System, and the Southeast Regional Center for Health Workforce Studies, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.

*Primary Care Physicians include active or unknown activity status, instate, nonfederal, non-resident-in-training MDs and DOs indicating a primary specialty of Family Practice, General Practice, Internal Medicine, Ob/Gyn or Pediatrics.

Surgeons per 10,000 Population*(# of Counties)

2.46 to 7.80 (21)1.58 to 2.45 (20)1.07 to 1.57 (20)0.01 to 1.06 (21)No Surgeons (18)

Surgeons per 10,000 PopulationNorth Carolina, 2004



*Physicians included are active or have unknown activity status, instate, nonfederal, non-resident-in-training MDs and DOs. Surgeons include physicians who reported a primary specialty in any type of surgery.

Other Specialists per 10,000 Population*(# of Counties)

7.73 to 49.20 (23)3.90 to 7.72 (23)1.50 to 3.89 (23)0.01 to 1.49 (24)No Other Specialists (7)


Other Physician Specialists per 10,000 PopulationNorth Carolina, 2004

*Physicians included are active or have unknown activity status, instate, nonfederal, non-resident-in-training MDs and DOs.Other specialists include physicians who reported something otherthan primary specialties in primary care or any type of surgery.


Percent Change, 1995-1999(# of Counties)

20.0% or More (48)10.0% to 19.9% (19)

0.01% to 9.9% (19)No Active Physicians in 1994 (1)-0.01% to -9.9% (8)

-10.0% to -19.9% (0)-20.0% or More (5)

Percent Change in Physicians per 10,000 PopulationNorth Carolina, 1995-1999

Source: North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, with data derived from the North Carolina Medical Board, 1995-2004.

*There were no active physicians in 1995; there were 3 active physicians in 1999.Counts include active, instate, nonfederal, non-resident-in-training physicians.


20.0% or More (10)10.0% to 19.9% (19)

0.01% to 9.9% (28)-0.01% to -9.9% (20)

-10.0% to -19.9% (10)-20% or More (13)

Percent Change in Physicians per 10,000 PopulationNorth Carolina, 1999-2004

Source: North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, with data derived from the North Carolina Medical Board, 1995-2004. Counts include active, instate, nonfederal, non-resident-in-training physicians.


20.0% or More (44)10.0% to 19.9% (14)

0.01% to 9.9% (20)No Active Physicians in 1995 (1)-0.01% to -9.9% (11)

-10.0% to -19.9% (5)-20.0% or More (5)

Percent Change in Primary Care Physicians per 10,000 PopulationNorth Carolina, 1995-1999


Counts include active, instate, nonfederal, non-resident-in-training physicians who indicated aprimary specialty of family practice, internal medicine, general practice, OB/GYN or pediatrics.

*There were no active physicians in 1995; there was 1 active physician in 1999.


20.0% or More (24)10.0% to 19.9% (22)

0.01% to 9.9% (17)-0.01% to -9.9% (21)

-10.0% to -19.9% (4)-20.0% or More (12)

Percent Change in Primary Care Physicians per 10,000 PopulationNorth Carolina, 1999-2004


Counts include active, instate, nonfederal, non-resident-in-training physicians who indicated aprimary specialty of family practice, internal medicine, general practice, OB/GYN or pediatrics.

Persistent HPSA Designation Status(# of Counties)

Whole County is PHPSA (21)Part of County is PHPSA (23)Not HPSA Designated (56)

Persistent Health Professional Shortage Areas* (PHPSAs)North Carolina Counties

*Persistent HPSAs are those designated as HPSAs by the Health Resources and Services Administration (HRSA) from 1993 to 1997, or in 6 of the last 7 releases of HPSA definition.Source: Area Resource File, HRSA, DHHS, 1998.Produced By: North Carolina Rural Health Research and Policy Analysis Center, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.

How to Change the Future Supply How to Change the Future Supply of Physiciansof Physicians

Factors in the SupplyFactors in the Supply

Medical School

Residency

INMigration

OUTMigration

Retirement

Death

Career Change

AccessibleSupply

Increase Entry the SupplyIncrease Entry the Supply

Medical School

Residency

INMigration

OUTMigration

Retirement

Death

Career Change

AccessibleSupply

Reduce Exit from the SupplyReduce Exit from the Supply

Medical School

Residency

INMigration

OUTMigration

Retirement

Death

Career Change

AccessibleSupply

NC Medical Schools, IN-State YieldNC Medical Schools, IN-State Yield(percent of graduates in active practice, in (percent of graduates in active practice, in

North Carolina)North Carolina)

Bowman-Gray-WFU..Bowman-Gray-WFU.. 39.4%39.4%Duke…………………..Duke………………….. 24.1%24.1%East Carolina………..East Carolina……….. 59.0%59.0%UNC-Chapel Hill…….UNC-Chapel Hill……. 48.7%48.7%

Yield from NC SuppliersYield from NC Suppliers

NC Medical Schools 40 year trend: NC Medical Schools 40 year trend: 39.3% of graduates practice in NC Current annual graduates: 441 2X graduates yields net increase of 171, after 7 years

NC Residencies 40 year trendNC Residencies 40 year trend 42% of those trained in NC stay in NC Current total Residents 2,640; 633 are in their 1st year 2X residencies yields net increase of 316, after 3.5 yrs

Birth States of Birth States of NC PhysiciansNC Physicians

n=17,000n=17,000

SC579

GA539

OH817

IL550

CA525

VA708

NY1691

NJ581

PA1000

Source: AMA Masterfile, December 31, 2003.

NC335420%

NC335420%

Where Graduates of NC Where Graduates of NC Medical Schools PracticeMedical Schools Practice

2003 data,2003 data, n=14,400n=14,400

NC510039%

NC510039%

SC577GA

579

FL719

TX411

CA803

TN419

VA779

NY412


Where NC Physicians Where NC Physicians went to Medical Schoolwent to Medical School

2003 data n = 17,0902003 data n = 17,090


SC640

GA658

OH817

IL566

VA984

NY1111

PA1036 NJ

581

TX606

NC456527%

NC456527%

Where physicians Where physicians who trained in NC who trained in NC

Residencies PracticeResidencies Practice 2003 data2003 data n=14,591n=14,591

TX491

CA469


NC856342%

NC856342%

SC515GA

550

FL692

TN397

VA673

PA328

MD319

Where NC Physicians Where NC Physicians Received Specialty Received Specialty

TrainingTrainingn=17,090n=17,090

NC617636%

NC617636%

SC628GA

563

OH789

VA1005

NY1424

PA1016

FL555

TX659

CA633


GY-1 Residency Fill Rate in North Carolina, 1995 - 2005

0%

20%

40%

60%

80%

100%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Number of GY-1 Residencies in North Carolina,1995 - 2005

633

0

100

200

300

400

500

600

700

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

National - State Policy ContextNational - State Policy ContextPresident cuts Title VII, AHEC from President cuts Title VII, AHEC from

BudgetBudgetCongress not mobilized to support Congress not mobilized to support

training programstraining programsStates facing need to expand States facing need to expand

residenciesresidenciesUtah: University-Intermountain System

Consortium to add state-funded residencies

State/Federal InitiativesState/Federal Initiatives

Kentucky-study shows need for 600 Kentucky-study shows need for 600 primary care physiciansprimary care physicians

Texas ,Georgia, Maryland: Texas ,Georgia, Maryland: Study/Analysis Groups, shortages Study/Analysis Groups, shortages notednoted

J-1 Visa program extended, J-1 Visa program extended, expanded PL 108-441.expanded PL 108-441.

Medical Schools Expanding ClassesMedical Schools Expanding Classes

Projections of Future SupplyProjections of Future Supply

Physician-Population Trends and Physician-Population Trends and ProjectionsProjections

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Total Active Physicians Population Primary Physicians

Focus on Short Term Future Focus on Short Term Future Population “Crosses” Physician Population “Crosses” Physician

GrowthGrowth

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

2004 2005 2006 2007 2008 2009 2010

Total Active Physicians Population Primary Physicians

Projection with 20% increase in Med. Projection with 20% increase in Med. School, Residency, In-migrationSchool, Residency, In-migration

physicians/10 000physicians/10 000

18

18.5

19

19.5

20

20.5

21

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Baseline Med Sch+20% + Res+20% Inmigration +20%

Documents

Trends in Physician Supply in North Carolina December, 2005 Thomas C. Ricketts, Ph.D. Erin Fraher, MPP; Katie Gaul, MA; Jennifer King, Hazel Hadley University