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
Supply of Active Physicians (MD & DO) and Ratio to Population Actual 1950 2010 and Projected to 2020 1,000,000 800,000 Physicians Per 100,000 Population Population is U.S. civilian population including possessions 195.9 297.4 299.2 277.4 906,278 988,100 236.9 776,301 Supply (Thousands) 600,000 400,000 200,000 155.6 142.2 141.6 453,165 323,799 259,443 219,897 601,237 0 1950 1960 1970 1980 1990 2000 2010 2020 Source: Bureau of Health Professions
Medical Schools Medical Education 5
Year Applicants to Allopathic Medical Schools and Enrollment No. of Applicants No. Accepted Applied: Accepted Ratio No. Enrolled Mean GPA of Applicants 1980 36,100 17,146 2.1 16,590 3.32 1992 37,408 17,464 2.1 16,289 3.24 1993 42,808 17,362 2.5 16,307 3.26 1994 45,364 17,317 2.6 16,287 3.28 1995 46,591 17,357 2.7 16,253 3.31 1996 46,967 17,385 2.7 16,201 3.34 1997 43,018 17,313 2.5 16,165 3.38 1998 40,998 17,374 2.4 16,170 3.40 1999 38,449 17,424 2.2 16,221 3.43 2000 37,092 17,538 2.1 16,301 3.44 2001 34,859 17,456 2.0 16,365 3.45 2002 33,625 17,592 1.9 16,488 3.46 2003 34,786 17,539 2.0 16,538 3.47 2004 35,735 17,662 2.0 16,648 3.47 2005 37,373 17,987 2.1 17,003 3.48 2006 39,108 18,442 2.1 17,370 3.48 2007 42,315 18,858 2.2 17,759 3.50 2008 42,231 19,135 2.2 18,036 3.50 2009 42,269 19,332 2.2 18,390 3.51
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
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
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
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
The Growth of Osteopathic Medical Schools (1968 2009) 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 16,893 35 30 25 20 15 10 5 Number of Colleges 0 1968 1973 1978 1983 1988 1993 1998 2003 2004 2005 2006 2007 2008 2009 Five year intervals 0
1 st Year MD and DO Enrollment 2014 as compared with 2002 2002 2014 # and % Increase MD 16,488 20281 3,405 23% DO 3,079 6,271 3192 103.7% Combined 19,567 26,552 6,597 35.7% Sources: AAMC Dean s Enrollment Survey: 2009 Preliminary Findings AACOM 2009 Survey on Osteopathic Medical School Growth Plans Preliminary Data
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)
Graduate Medical Education 14
Number of Residents in U.S. Allopathic Training Programs from 1993 2010 All residents First-year 120,000 100,000 No. of Residents 80,000 60,000 40,000 20,000 0 93-9494-9595-9696-9797-9898-9999-0000-0101-0202-0303-0404-0505-0606-0707-0808-0909-10 Academic Year Source: AMA
U.S. Allopathic Residents by Type of Medical School Attended 1993 2010 80,000 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 7,628 0 93-94 94-95 95-96 96-97 97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 09-10 Academic Year Source: AMA
The number of residents entering the ACGME pipeline grew 7% between 2002 and 2010 Source: ACGME
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. 293 25.0 (208,733) 60.2 U.K. 231 28.3 (39,266) 75.2 Canada 220 23.1 (15,701) 43.4 Australia 271 26.5 (14,346) 40.0 Source: Mullan, F. (2005). The Metrics of the Physician Brain Drain. NEJM: 353:1810-1818.
Rank Order of IMGs in the Physician Workforce of the US Source Country Number from Sending Country % of United States Workforce India 40,838 4.9 US IMGs 25,380 3.0 Philippines 17,873 2.1 Pakistan 9,667 1.2 Canada 8,990 1.1 China 6,687 0.8 USSR 5,060 0.6 Egypt 4,593 0.5 Mexico 4,578 0.5 S.Korea 4,401 0.5 Iran 4,002 0.5 UK 3,439 0.4 Dominic.Rep. 3,232 0.4 Syria 3,219 0.4 Germany 3,071 0.4 Lebanon 2,556 0.3 Nigeria 2,392 0.3 Argentina 2,374 0.3 Poland 2,365 0.3 Colombia 2,362 0.3
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 82,100 13.9 Indian Sub-Continent 78,680 656,876 10.7 Caribbean 8,010 87,443 8.4 Middle East and North Africa 27,010 489,464 5.2 Central and South America 12,103 707,416 1.7 Europe and Central Asia 44,988 2,741,717 1.6 East Asia and Pacific 39,910 2,808,400 1.4 North America 14,519 1,076,398 1.3
UME and GME Projection Scenarios Iglehart JK. N Engl J Med 2011;365:1340 1345. Source: AAMC
DOs in Training AOA & ACGME Comparison
Projected U.S. Medical School Graduates and First Year GME Approximately 7,000 IMGs also entered first-year GME in 2009. 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.
Physician Assistants Nurse Practitioners 25
PA Growth Newly Licensed PAs, 2000 2010 Newly Licensed PAs Source: National Commission on Certification of Physician Assistants Certified Physician Assistant Population Trends (PA Cs)
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 10,000 0 70 75 80 85 90 96 97 98 99 '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.
NP Growth Number of graduates Year Source: American Association of Colleges of Nursing 2000 2010 Annual Surveys 1 Analysis includes NP degree programs and post Master s NP programs; excludes joint NP/CNS program graduates.
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
So, what do we know and where are we going? 30
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
Medicare GME 32
Medicare GME Medicare GME history Enactment 1965 Prospective Payment System 1983 Balanced Budget Agreement 1997 ACA Supercommittee 33
Medicare GME Characteristics I Simple Predictable Generous Has built GME as we know it 34
Medicare GME Characteristics II Capped Wooden Not geared to the future 35
MCR GME Characteristics III Unaccountable Unresponsive Hospital centric Addictive 36
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
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
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
Allocation Options Central Regional State Local Consortia Other 40
Other Potential Funding Sources 41
Other Potential Sources Insurance surcharge ( All payer charge) Hospital revenues Medical practices Tuition Local authorities (millage, sales tax, etc.) (Medicaid) 42
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
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.