The Growth of the Physician Workforce 2012 and Beyond

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1 The Growth of the Physician Workforce 2012 and Beyond Fitzhugh Mullan, MD Murdock Head Professor of Medicine and Health Policy George Washington University Osteopathic Medical Education Leadership Conference January 12, 2012

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4 Supply of Active Physicians (MD & DO) and Ratio to Population Actual and Projected to ,000, ,000 Physicians Per 100,000 Population Population is U.S. civilian population including possessions , , ,301 Supply (Thousands) 600, , , , , , , , Source: Bureau of Health Professions

5 Medical Schools Medical Education 5

6 Year Applicants to Allopathic Medical Schools and Enrollment No. of Applicants No. Accepted Applied: Accepted Ratio No. Enrolled Mean GPA of Applicants ,100 17, , ,408 17, , ,808 17, , ,364 17, , ,591 17, , ,967 17, , ,018 17, , ,998 17, , ,449 17, , ,092 17, , ,859 17, , ,625 17, , ,786 17, , ,735 17, , ,373 17, , ,108 18, , ,315 18, , ,231 19, , ,269 19, ,

7 New Schools Since 2002 Commonwealth Medical College Oakland University Hofstra University Virginia Tech Rowan University Texas Tech University University of South Carolina, Greenville University of Central Florida Florida Atlantic 2010 AAMC. May not be reproduced without permission. Florida International University

8 New Schools Since 2002 Central Michigan University Oakland University Commonwealth Medical College Quinnipiac University California Northstate University Western Michigan University Hofstra University Virginia Tech Rowan University University of California, Riverside University of Arizona, Phoenix Texas Tech University University of South Carolina, Greenville Palm Beach Medical University of Central Florida Florida Atlantic 2010 AAMC. May not be reproduced without permission. Florida International University

9 New Schools Since 2002 Commonwealth Medical College Pacific Northwest Univ. COM Central Michigan University Oakland University Touro NY COM Quinnipiac University California Northstate University Rocky Vista Univ. COM Western Michigan University Hofstra University Virginia Tech Rowan University University of California, Riverside University of Arizona, Phoenix Lincoln Memorial Univ. COM Edward Via COM Texas Tech University University of South Carolina, Greenville William Carey Univ. COM A.T. Still University SOM Palm Beach Medical University of Central Florida Florida Atlantic 2010 AAMC. May not be reproduced without permission. Florida International University

10 New Schools Since 2002 Commonwealth Medical College Pacific Northwest Univ. COM Central Michigan University Oakland University Touro NY COM Quinnipiac University California Northstate University Rocky Vista Univ. COM Western Michigan University Hofstra University Marian University Virginia Tech Rowan University University of California, Riverside University of Arizona, Phoenix Lincoln Memorial Univ. COM Edward Via COM Campbell University Texas Tech University Alabama COM University of South Carolina, Greenville William Carey Univ. COM A.T. Still University SOM Palm Beach Medical University of Central Florida Florida Atlantic 2010 AAMC. May not be reproduced without permission. Florida International University

11 The Growth of Osteopathic Medical Schools ( ) Total Enrollment 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 1,879 2,780 Total Enrollment and Number of Colleges Male Enrollment Female Enrollment Number of Colleges, Branch Campuses and Teaching Sites 4,221 6,212 6,614 7,822 9,882 11,85712,525 15,634 13,406 14,409 18,143 16, Number of Colleges Five year intervals 0

12 1 st Year MD and DO Enrollment 2014 as compared with # and % Increase MD 16, ,405 23% DO 3,079 6, % Combined 19,567 26,552 6, % Sources: AAMC Dean s Enrollment Survey: 2009 Preliminary Findings AACOM 2009 Survey on Osteopathic Medical School Growth Plans Preliminary Data

13 Growth in enrollment comes from new and existing schools Anticipated Schools 16.6% increase as of 2011 New Schools Original schools Historical data Survey data Projections Source: AAMC Medical School Enrollment Survey (preliminary results)

14 Graduate Medical Education 14

15 Number of Residents in U.S. Allopathic Training Programs from All residents First-year 120, ,000 No. of Residents 80,000 60,000 40,000 20, Academic Year Source: AMA

16 U.S. Allopathic Residents by Type of Medical School Attended ,000 70,000 U.S. Allopathic U.S. Osteopathic IMG 70,218 67,524 68,647 66,893 67,111 67,085 67,316 65,820 65,661 66,646 67,131 68,456 69,721 68,578 70,056 71,119 71,871 60,000 No. of Residents 50,000 40,000 30,000 20,000 10,000 23,291 24,079 25,601 25,257 26,102 25,981 26,414 24,707 25,403 25,783 26,577 26,720 27,636 28,176 28,824 29,488 30,068 3,296 3,264 3,333 3,288 3,367 3,678 3,869 4,175 4,658 5,327 5,838 5,675 6,474 6,629 6,784 7,237 7, Academic Year Source: AMA

17 The number of residents entering the ACGME pipeline grew 7% between 2002 and 2010 Source: ACGME

18 Characteristics of Physician Workforces of US, UK, Canada, and Australia Country Physicians per 100,000 population % IMGs in MD workforce (total IMGs) % IMGs from lower income countries U.S (208,733) 60.2 U.K (39,266) 75.2 Canada (15,701) 43.4 Australia (14,346) 40.0 Source: Mullan, F. (2005). The Metrics of the Physician Brain Drain. NEJM: 353:

19 Rank Order of IMGs in the Physician Workforce of the US Source Country Number from Sending Country % of United States Workforce India 40, US IMGs 25, Philippines 17, Pakistan 9, Canada 8, China 6, USSR 5, Egypt 4, Mexico 4, S.Korea 4, Iran 4, UK 3, Dominic.Rep. 3, Syria 3, Germany 3, Lebanon 2, Nigeria 2, Argentina 2, Poland 2, Colombia 2,

20 Regional Emigration Factors Eight Regions of the World Global Regions Sending country MDs in recipient Countries by sending region Sending country MDs in sending region Emigration Factor Sub-Saharan Africa 13,272 82, Indian Sub-Continent 78, , Caribbean 8,010 87, Middle East and North Africa 27, , Central and South America 12, , Europe and Central Asia 44,988 2,741, East Asia and Pacific 39,910 2,808, North America 14,519 1,076,

21 UME and GME Projection Scenarios Iglehart JK. N Engl J Med 2011;365: Source: AAMC

22 DOs in Training AOA & ACGME Comparison

23 Projected U.S. Medical School Graduates and First Year GME Approximately 7,000 IMGs also entered first-year GME in Projects 1% annual growth in number of first-year GME positions. Data compiled by AAMC Center for Workforce Studies,7/2009 from 2008 AACOM and AAMC sources.

24

25 Physician Assistants Nurse Practitioners 25

26 PA Growth Newly Licensed PAs, Newly Licensed PAs Source: National Commission on Certification of Physician Assistants Certified Physician Assistant Population Trends (PA Cs)

27 Projected Number of People Eligible to Practice as PAs 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10, '00 '01 '02 '03 '05 10 Estimated Sources: Information Updates: Number of People in Clinical Practice as PAs, 1996, 1997, 1998, 1999, 2000, 2001, 2002, 2003, and AAPA Masterfile 10/13/2003.

28 NP Growth Number of graduates Year Source: American Association of Colleges of Nursing Annual Surveys 1 Analysis includes NP degree programs and post Master s NP programs; excludes joint NP/CNS program graduates.

29 Workforce Composition: Growth of PAs/NPs Compared to Physicians Ratio of Types of Direct Patient Care Providers, Supply and Production Providers Source: National Center for Health Workforce Analysis

30 So, what do we know and where are we going? 30

31 Future Demand and Supply Demand will grow Supply of medical graduates will grow but residency slots are not growing as fast Medicare GME is under scrutiny PA and NP graduates are growing rapidly as is their absorption into the workforce The expanded use of PAs and NPs will essential to meeting future service demand in primary and specialty care 31

32 Medicare GME 32

33 Medicare GME Medicare GME history Enactment 1965 Prospective Payment System 1983 Balanced Budget Agreement 1997 ACA Supercommittee 33

34 Medicare GME Characteristics I Simple Predictable Generous Has built GME as we know it 34

35 Medicare GME Characteristics II Capped Wooden Not geared to the future 35

36 MCR GME Characteristics III Unaccountable Unresponsive Hospital centric Addictive 36

37 What to do? Bay, howl, and plead Consider options to modernize the federal investment in GME to meet the demands of an evolving and growing health care system that is underperforming and over spending 37

38 Re Baselining Review and redefine the purpose of Medicare GME as an explicit commitment of public support for graduate medical education to address priority national workforce needs Determine the method of setting priorities Establish the system of allocation of positions 38

39 Priority Setting Designated authority (options) HHS MedPAC National Health Care Workforce Commission COGME Other Payment considerations Pay only for the core residencies Limit payments to certain specialties Etc. 39

40 Allocation Options Central Regional State Local Consortia Other 40

41 Other Potential Funding Sources 41

42 Other Potential Sources Insurance surcharge ( All payer charge) Hospital revenues Medical practices Tuition Local authorities (millage, sales tax, etc.) (Medicaid) 42

43 Nothing What Comes Next? Enactment of an All Payer GME system A failure of US graduates to secure residency positions Arbitrary GME cuts as part of a new budget deal Pressures to license IMGs without residencies Leadership deliberations within medical education proposing civic reforms to 43

44 African Proverb The best thing to do was to have planted a tree 20 years ago The next best thing is to plant the tree today.

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