CECS
Center for the
Evaluative
Clinical Sciences
The Troubled Physician Workforce:
Is a physician surge the answer?
David C. Goodman, MD MS
Professor of Pediatrics and of
Community and Family Medicine
The Center for the Evaluative Clinical Sciences
Dartmouth Medical School
Hanover, NH
2007 National Health Policy Conference
What are the desired outcomes of
medical workforce policy?
• Access to care when it is wanted and needed.
• Care that is technically excellent and personally
compassionate.
• Care that improves the health and well being of
patients and populations.
• Care that is affordable to the patient and to society.
The 2020 “Shortfall” and the Remedy
Physician Supply, Demand, and Need in the U.S. 2020
Council on Graduate
Medical Education:
1,400,000
1,240,000
1,173,000
1,200,000
1,076,000
1,086,000
1,000,000
1,027,00
972,000
800,000
Shortfall = ~90,000 or ~10%
600,000
Increase medical school
enrollment by 15%.
Increase or remove Medicare
Graduate Medical Ed. cap.
American Association of
Medical Colleges:
400,000
200,000
0
Supply
COGME. Sixteenth Report. 2005.
Demand
Need
Increase medical school
enrollment by 30%.
Eliminate the Medicare GME
cap.
The Per Capita Supply of Physicians Varies
~300% Across Regions
Specialists
250
110
225
100
200
90
175
80
300%
150
125
10%
Generalists
70
60
100
50
75
40
50
30
Dartmouth Atlas Hospital Referral Regions
Post-GME clinicians per 100K population age sex race adjusted - 1996
Regional variation in physician
supply is not explained by:
• Patient health status or health risk
Chan R, et al. Pediatrics 1997.
Goodman D, et al. Pediatrics 2001.
Wennberg J. Ed. Dartmouth Atlas of Health Care. Various editions. 1996 - 2006.
Fisher E, et al. Ann Int Med 2003.
Example 1: Are Neonatologists located
where newborn needs are greater?
Neonatologists per
1,000 Live Births
8.57
6.39
4.88
3.55
0.56
to 25.64
to 8.57
to 6.39
to 4.88
to 3.55
(50)
(49)
(51)
(46)
(51)
Example 1: Are Neonatologists located
where newborn needs are greater?
Neonatologists
Neonatologists
per 10,000 births
30
R2=0.04 *
25
*
20
*
*
*
15
*
*
* *
*
*
** * * **
**
*
*
*
** * * *
*
*
* ** * *
**
**
***** ********* * *
*
*
* *
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*
10
5
0
4
5
6
7
8
*
**
*
9 10 11 12 13
Percent Low Birth Weight
Goodman, et al. Pediatrics, 2001.
There is virtually no
relationship
between regional
physician supply
and health needs.
Example 2: Are Cardiologists located where
cardiac needs are greater?
Cardiologists per 100K
12.0
10.0
There is virtually no
relationship
between regional
physician supply
and health needs.
8.0
6.0
4.0
2.0
3.0
6.0
9.0
12.0
15.0
18.0
AMI Rate per 1,000 Medicare Enrollees
Source: Wennberg, et al. Dartmouth Cardiovascular Atlas
Regional variation in physician
supply is not explained by:
• Patient health status or health risk
• Patients preference for care
Fisher E, et al. Ann Int Med 2003.
NIA-CMS beneficiary survey, forthcoming.
No difference in preferences for aggressive care (dying in
hospital, mechanical ventilation, or drugs that would lengthen
their life, but make them feel worse)
No differences in concerns about getting too little (or too much)
treatment
Somewhat lower preference for palliative care that would shorten
life (80% want it in low spending regions, 75% in high spending).
So what?
Maybe more physicians leads to
better health outcome.
Example 3: Do areas with higher physician
supply have better health outcomes?
Mortality
Odds ratio
• Logistic models 1995 US
birth cohort
1.1
Better
Outcomes
Inefficient Care
• N = 3.8 million live births
• Dependent variable:
28 day mortality
1
0.9
0.8
Very Low
Low
Medium
High Very High
Quintile of Physician Capacity
Neonatologists
Source: Goodman, et al. New Engl J Med, 2002
Beyond a very low
supply, outcomes are
insensitive to
physician supply.
Example 4: Are health outcomes related to
physician labor inputs?
Last 6 Months of Life Chronic Disease Medicare Cohorts
(Full Time Equivalents per 1,000 beneficiaries)
Total
Primary
Care
Medical
Specialists
NYU Medical Center
28.3 FTE
8.8 FTE
15.0 FTE
RWJ University Hosp
19.8
4.3
12.2
Montefiore Med Center
16.5
6.5
7.1
MA General Hospital
15.3
6.3
5.5
Johns Hopkins Hospital
12.2
5.0
3.9
Yale-New Haven
10.6
3.4
4.4
UC, San Francisco
9.4
4.7
3.2
Mayo, Rochester MN
8.9
3.0
3.9
Source: Goodman, Health Affairs,March/April 2006.
So what?
Would a physician surge cause
any harm?
Where do more physicians go?
1979
For every physician that
settled in a low supply
region, 4 physicians settled
in a high supply region.
1999
Source: Goodman. Health Affairs, 2004.
High Physician Supply Regions:
• High bed capacity,
medical admission
rates.
• High physician visit
rates.
• High intensity care at
the end of life.
• High costs.
Sirovich B, et al. Ann Int Med 2006.
Wennberg J. Ed. Dartmouth Atlas of Health
Care. Various editions. 1996 - 2006.
Fisher E, et al. Ann Int Med 2003.
Fisher E, at al. Health Affairs 2004.
Fisher E, et al. Health Affairs 2005.
Goodman D, et al. Health Affairs 2006.
• Lower perceived access.
• No better patient
satisfaction.
• Worse technical quality.
• Greater tendency for
physicians to use
aggressive instead of
conservative treatment.
• Physicians perceive care to
be less available, less able
to provide quality care.
• No better and perhaps
worse patient outcomes.
Where would you invest $5 billion per
annum of public money in the
health care system?
• Improvements in care systems in an effort to improve
quality.
• Rewarding health care systems for improved outcomes.
• Implementation of the U.S. Preventive Services Task Force
recommendations.
• Expanding insurance coverage to children (S-CHIP).
• Health insurance for returning Iraq war vets who aren't
covered at their jobs.
• Establishment of effective post-marketing surveillance
system for drugs / devices.
• Increasing physician training rates?
The Center for the Evaluative Clinical Sciences
Dartmouth Medical School
Support
Collaborators
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John Wennberg, MD MPH
Elliott Fisher, MD MPH
George Little, MD
Therese Stukel, PhD
Jonathan Skinner, PhD
Katherine Baiker, PhD
Julie Bynum, MD
Scott Shipman, MD MPH
Douglas Staiger, PhD
Amitabh Chandra, PhD
James Weinstein, MD MS
David Wennberg, MD MPH
Sally Sharp, SM
Stephanie Raymond
Phyllis Wright-Slaughter, MHA
Daniel Gottlieb, MS
Kristen Bronner, MA
Vin Fusca, MMS
Megan McAndrews, MBA, MS
David Bott, PhD
Stephen Mick, PhD (VCU)
Chiang-hua Chang, MS
Nancy Marth, MS
Jon Lurie, MD MS
Ken Schoendorf, MD MPH (CDC/NCHS)
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The Robert Wood Johnson
Foundation
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Health Resources and Services Administration
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WellPoint Foundation
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Aetna Foundation
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United Health Foundation
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California HealthCare Foundation
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National Institute on Aging