Colorado’s
Primary Care Workforce
Estimating the impact of state and
national health reform on Colorado’s
primary care workforce
June 26, 2010
AcademyHealth’s Annual Research
Meeting,
g, June
J
26-28,, 2010
Boston, MA
A Presentation of the
Colorado Health Institute
1576 Sherman Street, Suite 300
Denver, Colorado 80203-1728
www coloradohealthinstitute org
www.coloradohealthinstitute.org
Acknowledgements…
Acknowledgements
• The Colorado Trust, major funder of CHI’s
workforce studies
• Colorado Health Professions Workforce
Policy Collaborative
• Workforce
f
Center
C
team at CHI
C
2
Goals of the Colorado’s Health Professions
Workforce Policy Collaborative
• To estimate the supply of and demand for Colorado’s
primary care workforce through 2025
• To identifyy primary
p
y workforce policy
p y issues for
policymakers that are amenable to intervention as
y
Colorado pplans for state and national health systems’
and insurance reforms
3
Physician supply and demand models
• Developed by Bureau of Health Professions, Health
Resources and Services Administration (HRSA)
• Supply model includes: mortality and retirements,
new entrants,
entrants type of physician (MD and DO) and
specialty
• Demand
D
d model
d l based
b d on population
l
projections,
current practice patterns, insurance status and
geographically
h ll adjusted
d
d physician-to-population
h
l
ratios
4
Inputs into HRSA physician supply model
Current active
physician workforce
(36 medical
di l
specialties, year of
medical school
ggraduation,, gender,
g
,
medical school
location
(U.S./Canada vs. all
other
th countries),
ti )
type of degree
(MD/DO), major
professional activityy
p
(direct patient care
vs. others)
New entrants
(1st year
residents +
physician inmigration into
Colorado)
DATA SOURCE: AMA Physician Master File
Separation
from workforce
(retirement and
d h)
death)
Physician
Supply
5
Inputs into HRSA physician demand model
Colorado
population
projections
j i
bby
gender and
geographic
distribution
(urban/rural)
Distribution of
population by
insurance
status by
gender and
geographic
distribution
(urban/rural)
Physician-topopulation
ratio by
gender,
geography
geography,
insurance
status
and
d physician
h i i
specialty
(primary care
and all other
specialists)
Physician
Demand
6
CO primary care physician supply and
d
demand
d model
d l development,
d l
2005-2025
2005 2025
• Phase I - Status quo primary care physician
supply
l and
dd
demand
d estimates
i
bbased
d on HRSA
algorithm
• Phase II – Alternative models estimating impacts
of a fully insured population, deferred physician
retirement and inclusion of PAs and advance
practice nurses, e.g., nurse practitioners
7
Status quo supply and demand equation for
primary care physicians, 2005-2025
Primary Care Demand
Primary Care Supply
23,000
21 000
21,000
19,000
17,000
15 000
15,000
13,000
11,000
SHORTAGE
9,000
7,000
451
131
5,000
1,551
940
3,000
2005
2010
2015
2020
2025
8
Primary care physician supply and demand:
Status quo and universal coverage, 2005-2025
Primary Care Demand
Primary Care Supply
Demand - All Coloradans Covered
11,000
9,000
+390
+370
7,000
SHORTAGE
1,551
+347
+322
5,000
131
451
940
3,000
1,000
2005
2010
2015
2020
2025
9
Making explicit the contributions of NPs and
PAs to the primary care workforce
• Phase 1 assumed that the current ratio of NPs and
PAs to physicians would be stable through 2025
(implicit inclusion)
• Phase II estimated changes the ratio of NPs and PAs
based on a “productivity/equivalency”
productivity/equivalency measure (set
at .8)
10
Inclusion of NPs and PAs in primary care physician
supply and demand equation, 2005-2025
Phase II Primary Care Demand
Base Primary Care Supply
Base Primary Care Demand
10,000
8,500
7,375
6,858
7,000
SHORTAGE
1,034
5,500
4,000
5,824
4,620
2,500
1,000
2005
2010
2015
2020
2025
11
Implications for primary care workforce planning
assuming expanded role for NPs and PAs
Challenges conventional wisdom about:
• Productivity
P d i i equivalency
i l
• Practice (i.e., collaborative, interdisciplinary) and
financing models (direct reimbursement, paying
for ppatient outcomes,, ACOs))
• Provider substitution versus “right care, right place,
right time
time”
12
Moving away from siloed health professions think to health
care teams promoting health and managing chronic illness
Implications of population aging for the supply of -• Physical,
y
occupational,
p
speech
p
and respiratory
p
y therapists
p
• LPNs, CNAs and personal care attendants in the home and
residential care environment
What and who will be needed to staff health homes in healthpromoting neighborhoods?
• Interdisciplinary health teams of physicians, nurses, social
workers, clinical pharmacists, mental and oral health
professionals
f i l supported
d bby neighborhood
i hb h d care management
teams
13
Limitations of current supply-demand
models
• Assumes an equilibrium point, in CO set at 2005
• Demand assumes physician productivity is a constant, doesn’t
allow
ll
for
f changing
h i practice
i patterns, hhealth
l h iinformation
f
i
technology, etc.
• Assumes that utilization
utilization, ii.e.,
e consumption of health care
services and payment mechanisms remain constant
• Workforce data woefully incomplete,
incomplete e.g.,
e g NP and PA practice
practice,
where? In what settings? Equivalency?
• No accounting for maldistribution of supply, physician
willingness to serve Medicare and Medicaid patients
14
Next steps …
• CHI funded to administer a PA and advance practice
nurse workforce survey to be completed by 12/2010
(adding to 11 completed surveys of CO’s workforce
completed by CHI)
• Newly released scan of innovative practice models
p
utilizingg NPs and PAs in CO featuringg 6 practices
around the state
• Developing alternative “models”
models to estimate supply
and demand for primary care in CO in partnership
with Workforce Collaborative
15