The U.S. Physician Workforce:
Beyond the Numbers
Richard A. Cooper, M.D.
Leonard Davis Institute of Health Economics
University of Pennsylvania
National Health Forum
Washington, DC
February 13, 2006
PHYSICIAN WORKFORCE - BEYOND THE NUMBERS
1. High quality health care requires adequate numbers of high
quality physicians.
2. The demand for health care services nationally will continue to
mirror the pace of economic growth.
3. Variation in the health care utilization among states will continue
to reflect regional differences in economic status.
4. Variation of health care utilization among small areas (hospital
regions, counties) will continue to reflect the additional burden of
socioeconomic disparities.
5. The training capacity of medical schools and residency programs
must be enlarged commensurate with the future demand that
flows from these economic and demographic realities.
Burden of Disease
Aging
Technology
GROWTH of ECONOMIC
CAPACITY
GROWTH of HEALTH CARE
SPENDING
DEMAND for
PHYSICIANS
Economic and demographic trends predict a continued
growth in the demand for physicians
Approx 2020-2025
Active Physicians per 100,000 .
of Population
400

GDP  2.0% per capita per year
350
300
2000
250
200
150
1929
GDP  1.0%

Health spending  ~1.5%

Health workforce  ~1.2%

Physician workforce  ~ 0.75%
100
$0
$10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
But supply will not keep up with demand.
Approx 2020-2025
Active Physicians per 100,000 .
of Population
400

350
300
2000
Projected Supply
250
200
150
1929
100
$0
$10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
And the “Effective Supply” will even be less.
Approx 2020-2025
Active Physicians per 100,000 .
of Population
400

350
300
2000
250
Projected Supply
Age
Gender
Lifestyle
Duty hours
Career paths
200
150
Effective Supply
1929
100
$0
$10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Variation in physician supply among states will
continue to reflect differences in economic status.
Physicians per
100,000 of Population
Physicians per 100,000 .
of Population
State Physician Supply and Per Capita Income
1970
400
350
300
250
200
1970
150
100
50
$10,000
$20,000
$30,000
$40,000
State Per Capita Income (1996 $)
DC Excluded
Data from Reinhardt, 1975
Physicians per 100,000 .
of Population
State Physician Supply and Per Capita Income
1996
400
350
300
250
200
1996
150
100
50
$10,000
$20,000
$30,000
$40,000
State Per Capita Income (1996 $)
DC Excluded
Physicians per 100,000 .
of Population
State Physician Supply and Per Capita Income
2004
400
350
300
250
200
2004
150
100
50
$10,000
$20,000
$30,000
$40,000
State Per Capita Income (1996 $)
DC Excluded
Physicians per 100,000 .
of Population
Constant Relationship between State Physician Supply
and Per Capita Income Spanning 35 years.
1970,1996 and 2004
400
350
300
250
2004
R = 0.6011
2
2004
200
1996
150
1970
1996
R = 0.5273
2
1970
R = 0.5129
2
100
50
$10,000
$20,000
$30,000
$40,000
State Per Capita Income (1996 $)
DC Excluded
1970 data from Reinhardt, 1975
DARTMOUTH
 More is Worse 
STATES
“States with more medical specialists
have higher costs and lower quality of care.”
Baicker and Chandra, 2004
"Physicians" per 100,000 of Population
State Quality vs “Physicians”
Baicker and Chandra
(Dartmouth “Residuals”)
220
210
200
More
Specialists
---------------Lower
Quality
190
Physician variable = “residuals after
controlling for total physician workforce.”
180
1
5
9
13 17 21 25 29 33 38
State Quality Rank
Higher  QUALITY  Lower
42
46 50
.
State Quality vs Physicians
Cooper
(Actual Data)
Physicians per 100,000 of Population
200
190
180
170
More
Specialists
---------------Higher
Quality
Physician variable = Physicians
160
1
5
9
13
17
21
25
29
33
State Quality Rank
Higher  QUALITY  Lower
38
42
46
50
DARTMOUTH
 More is Worse 
SMALL AREAS
Among Hospital Referral Regions (HRRs) with similar health
status, those with the greater expenditures do not have
▪ Better outcomes
▪ Better access to care
▪ Greater satisfaction
Fisher, et al, 2003
306 HOSPITAL REFERRAL REGIONS (HRRs)
Milwaukee HRR
Demographics of HRRs
% Metro
Fisher, Ann Int Med, 2003
100
87%
Metro
80
60
%
40
45%
Metro
20
0
1
Low
Cost
2
3
Quintile
4
5
High
Cost
Demographics of HRRs
% Black + Latino
Fisher, Ann Int Med, 2003
17%
Black +
Latino
16
12
% 8
4
6%
Black +
Latino
0
1
Low
Cost
2
3
Quintile
4
5
High
Cost
WISCONSIN HOSPITAL REFERRAL REGIONS (HRRs)
Milwaukee HRR
Wisconsin HRRs
Hospital days per 1,000 Ages 18-64
600
Milwaukee HRR
500
Milwaukee HRR
Madison HRR
400
Greenbay HRR
300
Appleton HRR
Neenah HRR
200
Lacross HRR
100
Marshfield HRR
0
day/1000_1864
Days per 1,000
Wausau HRR
MILWAUKEE HOSPITAL REFERRAL REGION
“Poverty Corridor”
42% of total population
92% of Black population
74% of Latino population
33% of income
Wisconsin HRRs
Hospital days per 1,000 Ages 18-64
600
Poverty Corridor
500
400
Milwaukee HRR
Milwaukee HRR
minus “Corridor”
300
Milwaukee Corridor
Milwaukee HRR
Milwaukee HRR - Corridor
Madison HRR
Greenbay HRR
Appleton HRR
200
Neenah HRR
100
Lacross HRR
Marshfield HRR
0
day/1000_1864
Days per 1,000
Wausau HRR
DARTMOUTH
 More is Worse 
FREQUENCY OF USE
“Supply-sensitive Services”
“The quantity of healthcare resources determines
the frequency of use.”
“Variations are unwarranted because they cannot
be explained by the type or severity of illness.”
Wennberg, BMJ 2002
FREQUENCY OF USE
Hospital Admissions in Poorest vs. Wealthiest Zones
of Milwaukee
8
7
6
Ratio of
Poorest 5
to
4
Wealthiest 3
Zones
2
1
0
Diabetes
Ages 35-64
Asthma
Ages 1-17
COPD
CHF
Ages 35-64 Ages 35-64
DARTMOUTH
 More is Worse 
FREQUENCY OF USE
Academic Medical Centers
“Our analyses (of end-of-life care) found three-fold
differences in physician FTE inputs for Medicare
cohorts cared for at Academic Medical Centers.
Given the apparent inefficiency of current physician
practices, the supply pipeline is sufficient to meet
future needs through 2020.”
Goodman et al, 2005
“Physician Inputs” into End-of-Life Care
at Academic Medical Centers
Goodman, et al, 2005
63 AMCs
15 AMCs
Newark
Chicago
Houston (2)
Philadelphia (3)
New York (2)
Los Angeles
Detroit (2)
Washington
Boston
Pittsburgh
12
8
Number of
AMCs
4
NYU
0
5
10
15
20
25
CPT-WRVU Equivalent FTE Physicians per 1,000
30
“Physician Inputs” into End-of-Life Care
at Academic Medical Centers
Goodman, et al, 2005
63 AMCs
15 AMCs
12
In large
urban
centers
Number of 8
AMCs
Three-fold
4
NYU
0
5
10
15
20
25
CPT-WRVU Equivalent FTE Physicians per 1,000
30
“Counter-clinical Conclusion”
More care should yield better outcomes, but…
…patients who receive the most needed care have
▪ more measured burden of illness
▪ more unmeasured burden of illness
▪ worse outcomes.
At the extreme: Intensive care units (ICUs) offer
the most needed care but have the worst mortality.
Kahn, et al. HSR Feb 2007
WHAT’S POSSILE FOR THE FUTURE?
The Supply-Demand dilemma
Physicians per 100,000 of population
.
400
350
200,000
too few
physicians
Demand
300
250
200
1980
Residencies
capped at
1996 level
1990
Supply
2000
Year
2010
2020
Increasing PGY-1 residency positions by 10,000 (40%)
over the next decade is essential,
but even that will not close the gap…
Physicians per 100,000 of population
.
400
350
Demand
+1,000/yr 2010-2025
300
No change
Supply
250
200
1980
1990
2000
Year
2010
2020
AAMC projects
17% increase in
medical school
enrollment
by 2012
= 2,500 additional
physicians/year in
2020
…and the gap will continue for decades.
None of us has ever experienced shortages such as these.
Physicians per 100,000 of population
.
400
+1,000/yr 2010-2030
350
Demand
300
250
Supply
No change
200
1980 1990 2000 2010 2020 2030 2040 2050
Year
PHYSICIAN WORKFORCE -- BEYOND THE NUMBERS
1. The training capacity of medical schools and residency
programs must be enlarged commensurate with future
economic and demographic demands.
2. Because so much time has been lost, chronic shortages of
physicians seem inevitable.
3. Inadequate domestic production will cause a further drain of
physicians from other countries, principally developing
countries.
4. An inadequate supply of physicians will lead to decreased
access to care for the most needy and deficiencies in care
overall.
Thank you
Economic Correlates and Units of Analysis
Comparison of Nations
“Society”
Inverse relationship
Direct relationship
200
150
100
> $23,000
50
< $23,000
Health Employment per 1,000
Admissions per Capita
Ages 18-64 .
250
ZIP Code Comparison
“Individual”
0
40
30
US
20
10
0
$-
$10,000 $20,000 $30,000 $40,000 $50,000
Per Capita Income
5,000
10,000
15,000
20,000
GDP per Capita ($ppp)
Small Area Analyses of Counties (3,141) and HRRs (306)
are intermediate between ZIP Codes (~25,000) and States or Nations
25,000
Economic growth will continue, and health care spending will
continue to grow more rapidly than the economy overall.
35
30
Cutler
% of GDP
25
20
CMS
15
10
NOTE: Under President Bush’s
proposed 2007 budget, annual growth of
Medicare spending would “shrink” from
8.1%, as currently projected, to 7.7%. .
5
0
1975
2000
2025
2050
2075
Had residency programs continued to expand after 1996,
the US would not now be facing severe shortages.
Physicians per 100,000 of population
.
400
350
If PGY-1 positions
had continued to
increase after 1996
at 500 per year
Demand
300
Supply
250
200
1980
1990
2000
Year
2010
2020
But had the “110% Rule” been put into place in 1996,
the current deficits would be even greater.
Physicians per 100,000 of population
.
400
350
Demand
300
Implementation
of the 110% Rule
in 1996
Supply
250
200
1980
1990
2000
Year
2010
2020