The Nation's Physician Workforce: Options for Balancing Supply and Requirements

Committee on the U.S. Physician Supply

Kathleen N. Lohr

Neal A. Vanselow, and

Don E. Detmer, Editors

Division of Health Care Services

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1996



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The Nation's Physician Workforce: Options for Balancing Supply and Requirements The Nation's Physician Workforce: Options for Balancing Supply and Requirements Committee on the U.S. Physician Supply Kathleen N. Lohr Neal A. Vanselow, and Don E. Detmer, Editors Division of Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1996

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The Nation's Physician Workforce: Options for Balancing Supply and Requirements National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is the president of the Institute of Medicine. Support for this project was provided by funds of the National Research Council and the Institute of Medicine (The W. K. Kellogg Foundation). Partial support was also provided by the Bureau of Health Professions of the Health Resources and Services Administration, U.S. Department of Health and Human Services, under Purchase Order No. 103HR960824P000-000. The views presented are those of the Institute of Medicine Committee on the U.S. Physician Supply and are not necessarily those of the funding organization. Library of Congress Catalog Card No. 95-72889 International Standard Book Number 0-309-05431-1 No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written permission from the publisher, except for the purpose of official use by the U.S. Government. Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, D.C. 20055 Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). First Printing, January 1996 Second Printing, April 1996 Copyright 1996 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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The Nation's Physician Workforce: Options for Balancing Supply and Requirements COMMITTEE ON THE U.S. PHYSICIAN SUPPLY DON E. DETMER,*† Co-Chair, Senior Vice President, University of Virginia, Charlottesville NEAL A. VANSELOW,* Co-Chair, Professor of Medicine, Tulane University School of Medicine, New Orleans, Louisiana CAROL A. ASCHENBRENER, Chancellor, University of Nebraska Medical Center, Omaha HOWARD L. BAILIT,* Senior Vice President for Health Services Research, Ætna Health Plans, Hartford, Connecticut SPENCER FOREMAN,* President, Montefiore Medical Center, Bronx, New York KAY KNIGHT HANLEY,† Hanley & Hanley, M.D., P.A., Clearwater, Florida M. ALFRED HAYNES,* Palos Verdes Peninsula, California ROBERT M. KRUGHOFF, President, Center for the Study of Services, Washington, D.C. EDWARD B. PERRIN,*† Professor, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle UWE E. REINHARDT,* James Madison Professor of Political Economy, Princeton University, Princeton, New Jersey MARY LEE SEIBERT,† Associate Provost, Ithaca College, Ithaca, New York GEORGE F. SHELDON, Professor and Chair, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill Study Staff Kathleen N. Lohr, Director, Division of Health Care Services Don Tiller, Division Administrative Assistant *   Member, Institute of Medicine. †   Member, Board on Health Care Services.

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The Nation's Physician Workforce: Options for Balancing Supply and Requirements Preface The U.S. health care system is in a period of enormous change. Catalyzed by market forces rather than government-initiated reforms, these changes are fundamental and are occurring rapidly. Although it is difficult to predict what the system will look like when a period of stability is reached, it is clear that the changes being made in its organization and in the financing of health care will have an impact on all components of the health care workforce. The numbers and types of health professionals required and the roles of each health profession will surely be much different in the future than in the past. This study by the Institute of Medicine (IOM) is the result of a number of widely held concerns about the size of the U.S. physician workforce and the direction in which it is moving. Despite numerous studies in the past 15 years, which have indicated that the U.S. physician supply will exceed requirements, the number of doctors in residency training has continued to grow each year. At the same time, there is evidence that the demand for physician services will be reduced as a result of the growth of managed care. All of this is taking place at a time that the United States has no coordinated and widely accepted physician workforce policy, as had been laid out during the period that comprehensive health care reform at the national level was being debated. Sensing that the nation was drifting in terms of a sound, defensible approach to its physician workforce needs and recognizing that a physician surplus carried at least the potential for adverse consequences, the IOM elected to undertake a short and focused study of the aggregate U.S. physician supply. The limited scope of the study should not be construed to imply the absence of other important physician workforce issues, such as specialty and geographic mal-

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The Nation's Physician Workforce: Options for Balancing Supply and Requirements distribution or lack of diversity. These problems are far from solved and must be addressed in their own right. The present study was designed to examine three questions: Is there an aggregate physician surplus? If there is a surplus, what is its likely impact on cost, quality, and access to health care and on the efficient use of human resources? What realistic steps might be taken to deal with any surplus that exists? A broadly representative IOM committee met on a single occasion to discuss these questions. Prior to the meeting, committee members were provided with an extensive series of relevant articles from the published literature and a background paper prepared by IOM staff. It is a tribute to the hard work of both committee members and Kathleen Lohr, Director of the IOM Division of Health Care Services, who staffed the study, that so much consensus on the three questions could be reached in the short time available. It is our hope that this report will stimulate renewed interest in physician supply issues and catalyze efforts to resolve the problems it identifies. Neal A. Vanselow, M.D. Co-Chair Don E. Detmer, M.D. Co-Chair

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The Nation's Physician Workforce: Options for Balancing Supply and Requirements Acknowledgments At its single meeting in July 1995, the committee profited greatly from thoughtful and informative presentations from two experts in this field—John Eisenberg, M.D., Chairman and Physician-in-Chief, Department of Medicine, Georgetown University; and Fitzhugh Mullan, M.D., Assistant Surgeon General and Director of the Bureau of Health Professions of the Department of Health and Human Services—and it wishes to express its deep appreciation for their efforts. Also very helpful were other staff of the Health Resources and Services Administration, including Carol Bazell, M.D., the government's project officer for the Bureau of Health Professions, Philip Salladay of the Bureau of Primary Health Care, and Robert Politzer, Chief, Workforce Analysis and Research. The committee also acknowledges the considerable assistance rendered to this project by several members of the Institute of Medicine (IOM) staff. Molla Donaldson, a senior staff officer, was generous in sharing materials and insights from a related study on primary care. Holly Dawkins, research assistant at the IOM, helped with checking facts and improving the manuscript at a key juncture. Moeen Darwiesh, the IOM's computer specialist, and Nina Spruill, the financial associate for the Division of Health Care Services, rendered key assistance when most needed. Finally, Don Tiller, the division's administrative assistant, graciously undertook to be project assistant at a time when he was already fully occupied.

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The Nation's Physician Workforce: Options for Balancing Supply and Requirements Contents     SUMMARY   1 1   INTRODUCTION   15     The Physician Workforce   16     The Match—or Mismatch—Between Supply and Requirements   17     Origins and Organization of the Study   19     Organization of This Report   21 2   U.S. PHYSICIAN SUPPLY AND REQUIREMENTS: MATCH OR MISMATCH?   23     Physician Workforce Issues Since World War II   23     Methods of Estimating Physician Supply Productivity, and Requirements   30     The Future Requirement for Physicians   33     International Comparisons   38     Match or Mismatch?   39     Conclusion   43     Notes   44     Appendix   46

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The Nation's Physician Workforce: Options for Balancing Supply and Requirements 3   RELATIONSHIP OF PHYSICIAN SUPPLY TO KEY ELEMENTS OF THE HEALTH CARE SYSTEM   49     Health Care Expenditures   50     Access to Care   53     Quality of Care   57     Other Issues in Production and Utilization of the Physician Workforce   64     Conclusion   69     Notes   70 4   STRATEGIES FOR ADDRESSING PHYSICIAN SUPPLY ISSUES   75     Do Nothing: The Free or Unregulated Market Approach   76     Institute Central Federal Regulation   77     A Constrained Market Approach   80     Concluding Statement   92     Notes   94     REFERENCES   97 APPENDIX:   BIOGRAPHIES OF COMMITTEE MEMBERS   105

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