The State of the Physician Workforce

The State of the Physician Workforce Michael J. Dill Director, Workforce Studies AAMC November 4, 2017 1

Projections Diversity Population 2

Projections Supply, demand, specialty groups 3

4

What s new? Updated data Refined hospitalists estimates Updated PA & APRN supply projections Population health scenario Metro/non-metro location data for demand and utilization equity 5

Key takeaways from the updated projections Physician demand continues to grow faster than supply Projected total physician shortfall of between 40,800 and 104,900 physicians by 2030 Shortages in both primary and specialty care with a particularly large shortage in surgical specialties Consistent with 2015 & 2016 projections reports 6

Supply scenarios include retirement, work hours, GME expansion Retire Earlier (-2) Millennial Hours Status Quo GME Expansion Retire Later (+2) 750,000 800,000 850,000 900,000 950,000 Projected FTE physician supply, 2030 Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. 7

Demand scenarios include ACA, APRNs/PAs, population health, retail clinics, managed care ACA + APRN/PA High ACA + APRN/PA Moderate ACA + Population Health ACA + Retail Clinics Status Quo ACA ACA + MC 750,000 800,000 850,000 900,000 950,000 1,000,000 1,050,000 1,100,000 Projected FTE physician demand, 2030 Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. 8

Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. An increasing overall shortage of physicians is projected through 2030 120,000 Total projected physician shortfall range, 2015-2030 104,900 Projected shortage, FTE physicians 90,000 60,000 30,000 40,800 2030 range 0 2015 2020 2025 2030 9

Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. The size and range of projected physician shortages varies by specialty group Projected physician specialty group shortfall ranges, 2030 Primary Care Specialties 7,300 43,100 Non-Primary Care 33,500 61,800 Medical Specialties 1,300 12,000 Surgical Specialties 19,800 29,000 Other Specialties 18,600 31,800 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 10

Projections Health care utilization equity & population health 11

We model Health Care Utilization Equity to better understand magnitude of unmet need What if barriers disappeared? How much more utilization (in 2015)? Scenario 1: Insurance & Metro/ Non-metro People without medical insurance and people living in non-metropolitan areas => utilization patterns equivalent to their insured peers living in metropolitan areas Scenario 2: Insurance, Metro/Nonmetro, & Race/Ethnicity Everyone => utilization patterns equivalent to white insured populations residing in metropolitan areas 12

Estimated Additional Physicians Needed if U.S. Had Achieved Health Care Utilization Equity in 2015 Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. Scenario 1: Insurance & Metro/ Non-metro 34,800 Additional Physicians Scenario 2: Insurance, Metro/Nonmetro, & Race/Ethnicity 96,800 Additional Physicians 13

Estimated Additional Physicians Needed if U.S. Had Achieved Health Care Utilization Equity in 2015 Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. Scenario 1 (Insurance, Metro) 10,300 Primary Care Scenario 2 (Insurance, metro, race) 21,800 Scenario 1 (Insurance, metro) Scenario 2 (Insurance, metro, race) 24,500 75,000 Specialty Care 14

We model population health measures to 15 better understand their long term workforce implications Scenario models the workforce implications of achieving selected Healthy People 2020 goals Sustained 5% body weight loss for overweight and obese adults Improved blood pressure, cholesterol, and blood glucose levels for adults with elevated levels Smoking cessation

Achieving population health goals would have different short- and long-term effects on demand Short-term: 1% decline in physician demand Long-term: 2% increase in physician demand (by 2030) Shifts in demand for select physician specialties Shifts in utilization across delivery settings 16

Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. Effect of achieving population health goals would differ across specialty groups Medical Specialties Other Surgery Primary Care 0 1,000 2,000 3,000 4,000 5,000 6,000 Net change in projected FTE physician demand by 2030 17

Projections Underlying trends: UME 18

19

US MD enrollment expected to exceed 30% increase 23,000 22,000 30% over 2002 US MD FIRST YEAR ENROLLMENT 21,000 20,000 19,000 18,000 17,000 16,000 All Schools (n=145) Original schools (n=125) Historical Data Survey Data Projections 15,000 2002 2005 2008 2011 2014 2017 2020 2023 Source: AAMC 2016 Medical School Enrollment Survey Report 20

Overall MD & DO first year enrollment is projected to grow 59% between 2002 and 2021 35,000 Projected MD and DO first year enrollment through 2021 30,000 First year enrollment 25,000 20,000 15,000 10,000 196% 35% DO MD 5,000 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Source: AAMC 2016 Medical School Enrollment Survey Report 21

Admissions/UME Clerkships Match/GME 22

Medical schools are increasingly concerned about clinical training opportunities for their students Percentage of schools concerned about clinical training opportunities 100% 80% 60% 40% 20% 0% 87.1% 79.6% 77.4% 72.6% 73.5% 54.0% Number of clinical training sites Supply of qualified primary care preceptors Supply of qualified specialty preceptors 2010 2016 Source: AAMC 2016 Medical School Enrollment Survey Report 23

Medical schools experiencing more difficulties with existing clinical training sites Percentage of schools experiencing difficulties with existing clinical training sites 70% 60% 50% 40% 30% 20% 10% 0% 11.1% High turnover among volunteer physicians 26.5% 28.0% 17.0% Difficulty in replacing retired physician volunteers 26.0% 53.0% Competition from osteopathic medical schools for clinical training sites 17.0% 34.9% Competition from offshore medical schools for clinical training sites 23.8% 62.1% Competition from other health care professionals (e.g., NPs, PAs) 32.0% 59.1% Pressure from existing clinical training sites regarding payment(s) for student rotations Source: AAMC 2016 Medical School Enrollment Survey Report 2009 2016 24

25

Adequacy of clinical opportunities for students an across-the-board concern 70% Percent of programs very concerned 60% 50% 40% 30% 20% 10% 0% Number of clinical sites Supply of primary care preceptors Supply specialty preceptors M.D. D.O. N.P. P.A. Source: Recruiting and Maintaining U.S. Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey. 26

Clerkship/clinical training sites were getting harder to develop & maintain 4 years ago 60% Percent of programs reporting much more difficult than two years prior 50% 40% 30% 20% 10% 0% Identify and develop new core or required training sites M.D. D.O. N.P. P.A. Maintain and preserve existing core or required training sites Source: Recruiting and Maintaining U.S. Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey. 27

Projections Underlying trends: GME 28

Percentage of schools concerned about graduate medical education, 2012 2016 PERCENT OF SCHOOLS REPORTING MAJOR OR MODERATE CONCERN 35% 47% 48% 50% 39% 67% 76% 71% 62% 62% 84% 91% 86% 77% 80% FOR MY INCOMING STUDENTS IN MY STATE NATIONALLY 2012 2013 2014 2015 2016 Source: AAMC 2016 Medical School Enrollment Survey Report 29

Production of new physicians not keeping up with aging workforce and population 58,000 + 97% 20,000 53,000 Residents/Pop. 65+ in thousands 48,000 43,000 38,000 33,000 28,000 + 36% + 19% 17,500 15,000 12,500 Physicians turning 65 23,000 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 10,000 Residents entering ACGME Pop 65+ Physicians turning 65 Source: ACGME, Census, AMA Physician Masterfile; US Census Bureau 30

Projections Underlying trends: Physician practice 31

Numbers of new PAs and NPs still growing rapidly 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: NCCPA; AACN. NP Graduates Newly Licensed PAs 32 UPDATE

The shift in physician work hours has varied by age group 60 Average physician work hours per week 55 50 45 40 35 30 26 to 35 yrs 36 to 45 yrs 46 to 55 yrs 56 to 65 yrs Total age 66 or older 1980 1990 2000 2009-2011 2012-2014 Source: Census (Decennial/ACS). 33

The shift in physician work hours has varied by age group and sex 6 3 Change in average male physician work hours, 1980 to 2012-2014 +2.1 6 3 Change in average female physician work hours, 1980 to 2012-2014 +3.8 +2.5 +5.8 +3.5 +0.8 0 0-1.1-0.4-3 -6-5.8 MALE 26 to 35 yrs 36 to 45 yrs 46 to 55 yrs 56 to 65 yrs 66 + yrs -3-6 -3.9 FEMALE 26 to 35 yrs 36 to 45 yrs 46 to 55 yrs 56 to 65 yrs 66 + yrs Source: Census (Decennial/ACS). 34

The US physician workforce is getting older 250,000 Number of Physicians Who Worked in Prior Year 1980 1990 2000 2010 200,000 150,000 100,000 50,000 0 Age 26 to 35 Age 36 to 45 Age 46 to 55 Age 56 to 65 Age 66 or older Source: United States Census Bureau. Note: Data for 2010 are a combination of 2009, 2010, 2011 American Community Surveys. *In 2000 and 2010, Other includes two or more races 35

Retirement scenarios remain the most extreme physician supply projections Projected FTE Physician Supply: All Physicians 880,000 Retire Later +2 GME Expansion Status Quo 830,000 Millennial Hours Retire Earlier -2 780,000 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. 36

Technology can improve access to a wide array of services From a patient perspective, we ask about: Viewing lab results online Making appointments online Telephone communication Email communication Video communication 37

Consumers report overall increases in most types of technology use 38

Largest divergence in consumers use of technology reported for video communication 39

Workforce Diversity 40

Physician workforce in the US continues to grow and to include more female physicians 800,000 600,000 Number of Physicians Who Worked in Prior Year 612,549 709,382 400,000 346,660 454,539 200,000 0 1980 1990 2000 2010 Male Source: United States Census Bureau Note: Data for 2010 are a combination of 2009, 2010, 2011 American Community Surveys Female 41

Physician workforce is slowly becoming more racially and ethnically diverse 1,000,000 Number of Physicians Who Worked in Prior Year 750,000 500,000 250,000 0 2000 2005 2010 2015 White Black American Indian or Alaska Native Asian or Pacific Islander Two or more major races Hispanic, any race Source: United States Census Bureau. Note: Data for 2010 are a combination of 2009, 2010, 2011 American Community Surveys. *In 2000 and 2010, Other includes two or more races 42

North Carolina makes a good case study in the need to understand workforce diversity in context Data Source: 2015 American Community Survey 5-year Estimates; 2014 North Carolina Physician Licensure Data 43

Black or African American population and physician distributions dissimilar Population Data Source: 2015 American Community Survey 5-year Estimates; 2014 North Carolina Physician Licensure Data 44

American Indian / Alaska Native population and physician distributions somewhat similar Population Data Source: 2015 American Community Survey 5-year Estimates; 2014 North Carolina Physician Licensure Data 45

IMGs comprise a significant part of the nation s physician workforce 24.5% of 2016 active physicians were International Medical Graduates (IMGs). 1 24.9% of 2015-2016 active residents were International Medical Graduates (IMGs). 2 1 2017 State Physician Workforce Data Report, AAMC Workforce Studies. 2 2016 AAMC Report on Residents, December 2016 46

Deferred Action for Childhood Arrivals (DACA) program uncertainty could impact workforce diversity Students with DACA status: 113 Applied to U.S. medical schools for the 2016-2017 year 65 Enrolled in U.S. medical schools in the 2016-2017 year AAMC expects increased enrollment of DACA Dreamers in 2017-2018 since most with confirmed DACA status have not yet finished their undergraduate degrees. 1 https://www.forbes.com/sites/brucejapsen/2017/09/05/how-trumps-move-to-end-daca-worsens-the-doctor-shortage/#738df05d5b06. 47

Education pipeline Diversity 48

Small but important gains from medical school expansion Most expansion - highest proportions in primary care and practicing in underserved and rural areas. Racial and ethnic diversity of matriculants increased modestly - new schools contributed disproportionately. Shipman, Jones, Erikson, & Sandberg. 2013. Exploring the Workforce Implications of a Decade of Medical School Expansion: Variations in Medical School Growth 49and Changes in Student Characteristics and Career Plans. Academic Medicine 88(12): 1904 1912.

Percentage of U.S. medical school graduates by sex, 1980-2015 80% 70% 60% 50% 40% 30% 20% Female Male 10% 0% 1980 1985 1990 1995 2000 2005 2010 2015 Source: AAMC Data Warehouse: Student file, as of 1/7/2016. 50

Percentage of U.S. medical school white graduates by sex, 1986-2015 80% 70% 60% 50% 40% 30% 20% Female Male 10% 0% 1986 1990 1995 2000 2005 2010 2015 Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016. 51

Percentage of U.S. medical school Hispanic graduates by sex, 1986-2015 80% 70% 60% 50% 40% 30% Female 20% Male 10% 0% 1986 1990 1995 2000 2005 2010 2015 Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016. 52

Percentage of U.S. medical school Asian graduates by sex, 1986-2015 80% 70% 60% 50% 40% 30% 20% Female Male 10% 0% 1986 1990 1995 2000 2005 2010 2015 Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016. 53

Percentage of U.S. medical school American Indian/Alaska Native graduates by sex, 1986-2015 80% 70% 60% 50% 40% 30% 20% 10% Female Male 0% 1986 1990 1995 2000 2005 2010 2015 Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016. 54

Percentage of U.S. medical school Black or African American graduates by sex, 1986-2015 80% 70% 60% 50% 40% 30% 20% 10% 0% Female 1986 1990 1995 2000 2005 2010 2015 Male Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016. 55

Percentage of U.S. medical school female, 1986-2015 80% 70% 60% 50% 40% 30% 20% 10% Hispanic Black or African American Asian White 0% 1986 1990 1995 2000 2005 2010 2015 Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016. 56

After 30+ years, Black male matriculation is slowly increasing above 1980 levels Male matriculants to US medical schools, 1980 to 2017 800 Black/African American 700 Black Alone 600 Black Alone or in Combination with Another Race 500 400 300 200 100 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Source: AAMC AMCAS APP_BIO tables. Race is only available for permanent residents. 57

Most USMD schools have programs or policies designed to recruit a diverse student body Percentage of programs Minority groups currently underrepresented in medicine 90% Students with disadvantaged backgrounds 88% Students from rural communities 60% Students from underserved communities 61% Students from local underserved communities 70% 0% 25% 50% 75% 100% Source: AAMC 2016 Medical School Enrollment Survey Report 58

Recruitment programs begin in elementary school Percentage of schools with specific admissions programs or policies Elementary school students 23% Middle school students 59% High school students 91% Community college students--nationwide 8% Community college students--local 42% Four-year-university students--nationwide 59% Four-year-university students--local 86% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: AAMC 2016 Medical School Enrollment Survey Report 59

Demand Population 60

Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. More absolute future growth in utilization projected from whites than other groups Projected Growth in Physician Demand by Patient Race and Ethnicity 70,000 60,000 50,000 40,000 30,000 20,000 10,000 Projected growth in FTE physician demand, 2015 to 2030 0 White Black Asians, Pacific Islanders, Native Americans, and Alaskan Natives Hispanic 61

Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. Much faster utilization growth rates projected for other groups than for whites 60% Projected Growth in Physician Demand by Patient Race and Ethnicity 50% 40% 30% 20% 10% 10% Projected percentage growth in FTE physician demand, 2015 to 2030 25% 45% 49% 0% White Black Asians, Pacific Islanders, Native Americans, and Alaskan Natives Hispanic 62

Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030. The vast majority of physician demand current and projected is in metropolitan areas FTE physician demand FTE physician demand Metro, 2015 Metro, 2015-2030 Non-metro, 2015 Non metro, 2015-2030 300,000 300,000 250,000 250,000 200,000 200,000 150,000 150,000 100,000 100,000 50,000 50,000 0 Primary Care Medical Specialties Surgery Other 0 Primary Care Medical Specialties Surgery Other 63

Access to care Population 64

AAMC collects data on health care access from consumers Needed care last 12 months-always able to get it, 50% Did not need care, 43% Could not afford, 3% Could not get appointment soon enough, 1% Could not find provider, 2% 7% of U.S. adults (>17 million people) could not always get care Transportation problems, 1% Other, 0% Source: AAMC Consumer Survey of Health Care Access (June, 2017) 65

LGB individuals consistently face greater challenges accessing care 29 23 25 22 Gay, lesbian, or bisexual 14 17 14 12 Heterosexual or straight Source: AAMC Consumer Survey of Healthcare Access. 66

Access to care appears to be improving, though racial/ethnic disparities persist 35 Percent of respondents not always able to get care 30 25 20 15 10 5 0 White Black/African American Hispanic and Other Asian Hispanic/Latino Multi-race (non- Hispanic) 2011 2017 Source: AAMC Consumer Survey of Health Care Access Native Hawaiian/Other Pacific Islander & Other excluded due to sample size. American Indian/Alaska Native 67

The nation s rural population is not homogenous 68

Rural access varies by race/ethnicity 69

The diversity of American medicine and the conversations, ideas and breakthroughs this diversity sparks may be one reason for our competitiveness as a global leader in biomedical research and innovation. - Dhruv Khullar, MD Aaron Carroll, Why America Needs Foreign Medical Graduates. https://www.nytimes.com/2017/10/06/upshot/america-is-surprisingly-reliant-on-foreign-medical-graduates.html 70

The AAMC Workforce Studies Team Da Shia Davis, BS Kara Fisher, MPH Sarah Hampton, BA Karen Jones, MApStat Scott Shipman, MD Imam Xierali, PhD Preeti Iyer, BSE (in progress) Michelle Ogunwole, MD 71

Data Snapshots 72

Physician data reports State and specialty rankings and data on: Physician Supply UME/GME In-State Retention 73

mdill@aamc.org www.aamc.org/workforce 2018 Health Workforce Research Conference Tysons, VA May 9-11, 2018 74

Production of new physicians not keeping up with aging workforce and population 58,000 + 97% 20,000 53,000 Residents/Pop. 65+ in thousands 48,000 43,000 38,000 33,000 28,000 + 36% + 19% 17,500 15,000 12,500 Physicians turning 65 23,000 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 10,000 Residents entering ACGME Pop 65+ Physicians turning 65 Source: ACGME, Census, AMA Physician Masterfile; US Census Bureau 75

PROJECTIONS SHORTAGES NOT KEEPING UP WITH AGING Projections Pulling it all together Diversity DIVERSITY A GOOD THING PROGRESS NEED MORE PROGRESS Population POPULATION AGING DIVERSE DEALING WITH DISPARITIES 76

Where do we go from here? Extent of current shortages Work hours and retirement PAs and APRNs Clinical training/clerkships Distribution solutions Pipeline programs Keep tracking access 77

Questions? 78