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OCR for page 261
Chapter It
SUPPLY OF PHYSICIANS FOR THE FUTURE: WHAT ARE THE NEEDS?
Nancy C. Ahern, Alvin R. Tarlov, Frank A. Sloan
Introduction
It is estimated that the aggregate supply of physicians in the
United States will increase by one-third in the 1980s and by more than
one-half over the period 198o-2ooo.l The total U.S. population, by
comparison, is expected to increase by only lo percent in the 1980s
and 18 percent through the year 2000.2 Thus the pattern of the last
15 years will continue, with a steady rise in the supply of health
professionals in proportion to population.
Private sector recommendations and federal legislation affecting
recent growths
Much of the expansion in physician supply in the late 1960s and
early 1970s can be traced to concern expressed as early as l9S9 that
the future supply of physicians would not be adequate for an
increasing population unless new medical schools were constructed and
the numbers of students in existing schools were increased.4
However, several years elapsed before the recommendations were
buttressed by f ederal legislation--the Health Professions Educational
Assistance Act of 1963, whi ch provided funds for construction.
Further alarms of an impending shortage of physicians were sounded
in 1964 in the Coggeshall report to the Association of American
Medical Colleges (AAMC ~ . The report concluded that "more physicians
must be trained as quickly as possible . . . . It must be recognized,
however, that it is not likely that America will ever be able to
produce all the physicians that the nation would like to have."5
The concept of shortage was reiterated in 1967 in the report of
the President's National Advisory Committee on Health Manpower. It
was recommended that "production of physicians . . . be increased
beyond presently planned levels by a substantial expansion in the
capacity of existing medical schools and by continued development of
new schools."6
Both the American Medical Association (~MA) and the AAMC endorsed
this policy in a joint statement released in February 1968 and agreed
"that all medical schools should now accept as a goal the expansion of
their collective enrollments ~o a level that permits all qualified
applicants to be admitted."7 Soon thereafter ~ health manpower act
was passed by Congress; it provided loan and scholarship money, as
well as funds for construction and operating costs of medical
schools. Eligibility for funds was linked to a requirement to
increase the school's class size (capitation grants).
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Medical school enrollments
As a result of the private sector consensus and the infusion of
government funds, the number of U. S. medical schools increased in
number from 89 in ~ 965 to 127 in 1982 (Table 1) . Enrollments of
first-year students nearly doubled over this period from about 9~000
in 1966 to more than 17,000 in 1982 (Table 1 and Chapter 7, Table 2~.
Osteopathic school enrollments have grown at similar rates (Table 2 ~ .
Enrollments in allopathic schools have fallen off slightly, as of
the 1982/83 academic year, and are expected to remain at this reduced
level or to continue a modest decline in the next few years. However,
because of the time lag in training, the number of graduating medical
s tudents will continue to rise through 1985, and the number of new
entrants to medical practice will not peak until about 1990.
TABLE 1 Enrollment of First-year Medical Students, 1965 to 1982,
Allopathic Schools
Academic Year Number of New First-year Increase from
Beginning Fall Schools Enrolleesa Previous Year
1965 89 8,554 ~~
1966 92 8~775 2~6%
1967 95 9~314 6~1
1968 99 9 ~ 740 4 ~ 6
1969 101 10~269 5~4
1970 103 11 ~ 169 8.8
1971 108 12~088 8~2
1972 112 13 ~ 570 12 ~ 3
1973 114 13 ~ 876 2 ~ 2
1974 114 14~579 5~1
1975 114 14~910 2~3
1976 116 15 ~ 282 2 ~ 5
1977 122 15~493 1~4
1078 125 16,054 3 e 6
1979 126 16 ~ 301 1 ~ 5
1980 126 16 ~ 590 1 ~ 8
1981 126 16~644 0~3
1982 127 16 ~ 567 ~0.5
aThe number of new enrollees will differ from the total number of
first-year students as the latter includes those repeating the year.
In 1982/83 for example, there were 17,254 first-year students, but
only 16,567 new enrollees.
SOURCE: Association of American Medical Colleges, unpublished data.
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TABLE 2 Enrollment of First-year Medical Students in Osteopathic
Schaol~. 1965-1982
Academic Year Number of Firat-year
Beginning Fall Schools Enrollmenta
1965 5 464
1966 5 480
1967 5 509
1968 5 521
1969 6 577
1970 7 623
1971 7 670
1972 7 810
1973 7 884
1974 9 905
i975 9 - 1,002
1976 10 1,068
1977 12 1,207
1978 14 1,322
1979 14 1,381
1980 14 1,478
1981 15 1,564
1982b 15 1,681
aMay include students repeating the f irat year.
bEs timated.
SOURCES: Reference #1, Table IV-24; and 1982-83 Yearbook of
Osteopathic Physicians. Chicago: American Osteopathic Association,
1982.
Inflow of Foreign Medical School Graduates
The annual inflows of F14Gs have been very uneven, reflecting
changes in health manpower policies, and immigration and licensing
policies (Table 3~. As a group, FMGs represented nearly one-third of
the additions to total physician supply between 1966 and 1976.1 In
1981/82, FrMGs accounted for 25 percent of all residents in f irat-year
postgraduate training and 19 percent of all residents (Table 4 ~ .
Nearly half of all E~MG residents were United States citizens who
studied abroad. The recent increase in numbers of FMGs is due to the
increase in U.S. FMGe (Table 4~. It is now believed that a largely
new category of FMG, the unemployed European doceor,~is attempting to
enter the physician work force in the United States.
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TABLE 3 Numbers of Initial Licenses Issued by State Boards of Medical
Examiners, Selected Years 1960 to 1981
Fogs as
Total New Percent of
Year Physicians FMGs Total
1960 8,030 1,419 18
1963 8,283 1,451 18
1968 9,766 2,185 22
1970 11,032 3,016 27
1971 12,257 4,314 35
1972 14,476 6,661 46
1973 16,689 7,419 44
1974 16,706 6,613 40
1975 16,859 5,965 35
1976 17,724 6,436 36
1977 18,175 5,851 32
1978 19,393 4,578 24
1979 19,896 3,566 18
1980 18,172 3,310 18
1981 18,831 3~131 17
SOURCE: U.S. Medical Licensure Statistics 1980-81 and Licensure
Requirements 1982. A. V. Daigle, et. Chicago: American Medical
Association, 1982.
TABLE 4 Foreign Medical Graduate Participation in Graduate Medical
Education, 1979 to 1981
. . .
First Postgraduate Year
Filled
Year Positions Fags
~ . .
All Residency Years
Filled
Positions FMGs US FMGs
1979 -- 3~787 64~615 12~070 4,229
1980 18~702 4J018 62,853 12~078 4~790
1981 18,389 4,715 69,738 13,194 5,838
SOURCE: Medical education in the U. S . 1980~1981 . JAMA 246: 2911-2986,
1981; and ISetlcal education in the U.S. 1981-1982. JAMA 248:3223-3328,
1982.
264
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Projections of future supply
Projected increases in physician supply are detailed in two recent
studies: the 1980 report of the Graduate Medical Education National
Advisory Committee (GMENAC),9 and the 1982 report to Congress by the
Bureau of Health Professions (BHPr) of the Department of Health and
Human Services.1
The GMENAC report estimated that the supply of physicians would
reach 536,000 by the year 1990, and 643,000 by the year 2000 (Table 5~.
The total supply figures were projected using a mathematical model
that started with the present supply and (~) adjusted for attrition
through death, disability, and retirement; and (2) adjusted for
additions of United States medical school graduates, foreign medical
graduates, and residents in training.
The GMENAC pro jections assumes that numbers of U. S . medical
students entering allopathic schools would increase 2.5 percent per
year between 1978/79 and 1981/82 and then remain constant at 18,151;
that numbers entering osteopathic schools would increase 4.6 percent
per year through 1987 and then remain constant at 1,868; and that
numbers of FMGs entering residencies in the United States would
increase to 4~100 by 1983/84 and then remain constant. Residents in
training were included in the supply figures as 0.35 full-time
practice equivalent.
We now know that enrollments through the remainder of the 1980s
will probably be lower than GMENAC expected (e.g., in 1982/83,
first-year enrollments were 17,254 rather -than the 1S,151 projected).
However, the current numbers of entering P~Gs are somewhat higher than
expected--4, 500 versus 4 ,100. Thus, in balance, the GMENAC estimates
of total future physician supply are not too different from what they
would be if the calculations were repeated today.
The Bureau of Health Professions more recent report estimates that
the total supply of M.D. arid D.O. (Doctor of Ostepathy) practitioners
will climb to 591,200 by the year 1990, representing a 32 percent
increase over 1980 (Table 6). The BlIPr pro Sections are higher than
those of G~NAC, since they count residents as full-time equivalents
of practicing physicians, while GMENAC included residents at the rate
of 0.35 their number.
Whatever the pro Section methodology, it is clear that the pool of
physicians in the Uni ted States has grown sharply and will continue to
grow into the 1990~. We know reasonably well how many doctors the
nation will have in 1990. What their geographic and specialty
distribution will be and how many will be required to meet the health
needs of the population, and consequently how many should be trained,
is much less certain, as discussed below.
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TABLE 5 Physician Supply Pro jected by GMEN~C, and U. S O Population,
1978 1990 and 2000
· ,
Increase
1978 1990 2000 1978-1990
Physician supplya 374,800 535,750 642,950 43X
U. S. population
in thousands
Physicians per
]~i~2 Population
218, 717b 249,731C 267,990C 14:
171
215
240 26%
NOTE: The major cause of difference between physician supply and
projections in Tables 5 and 6 relates to the method by which the
70,000 residents in training are counted. The BHPr counted each
resident as one physician, while GMENAC counted each resident as
one-third of a full-time equivalent practicing physician.
aPhysician supply includes all professionally active physicians
(M.D. 's and D.O. 's) together with 0.35 of all residents and fellows in
training in the year indicated. The 1990 and 2000 figures pro jected
by G~3NAC assumed that U.S. allopathic medical school first-year
enrollment would increase 2.5 percent per year between 1978/79 and
1982/83 and then remain level at 1B,151; that osteopathic school
enrollment would increase 4.6 percent per year between 1978/79 and
1987/88 and then remain level at 1,868; and that FMGs would be added
to the residency pool at the rate of 3,100 per year in 1979/
increasing to 4,100 per year by 1983, ant then remain level.9
bU. S. Bureau of Census, Current Population Reports, Estimates of
IJ. S. Population to May 1, 1980. Series P-25, No . 888, July 1980.
CU. S. Bureau of Census, 9~, Pro jections of
the Population of the U. S.: 1982 to 2050 (advance report ). Series
P-25, No . 922, October 1982.
266
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TABLE 6 Physician Supply Pro jected by Bureau of Health Professions,
and U. S. Population, 1980, 1990, and 2000
Increase
1980 1990 2000 1980-1990
Physician supplya 449, 500 591, 200 704, 700
U.S. population 227~658 249~731 267~990 10Z
in thousandsb
Physicians per 197 237 263 20%
100,000 population
NOTE: The major cause of difference between physician supply and
projections in Tables 5 and 6 relates to the method by which the
70,000 residents in training are counted. The B8Pr counted each
resident as one physician, while GMENAC counted each resident as
one-third of a full-time equivalent practicing physician.
aPhysician supply includes all active physicians, M.D.'s and D.O.'s,
as well as all residents in training in the year indicated. The
projections assume that firat-year enrollments in allopathic and
osteopathic schools will decline S percent over a 5-year period
beginning in 1983, and will then level off at 16,800 M.D. and 1,600
D.O. first-year entrants in 1987, remaining at these levels through
the end of the pro Section period . Assumptions regarding additions of
foreign medical graduates were as. follows: (1) alien FMGs entering
under family preference visas are expected to average 900-1,100
annually; (2) alien FMGs entering under other than family preference
are expected to average 1,600 annually; (3) U.S.-citlzen PrMGs are
expected to average 1, 500 annually during the first half of the 1980s
and then level of f during the latter l980s to about one-third that
numbe r . 1
bU. S. Bureau of Census, Current Population Reports, Pro ject ions of
the Population of the U. S.: 1982 to 2050 (advance report ). Series
P-2 5, No . 922, October 1982.
l
Supply of Nonphysician Providers
The increase in numbers of practicing physicians has been
accompanied by a parallel rise in the supply of nonphysician health
care providers. Between 1965 and 1980, the pool of registered nurses
(RNs) increased by more than 100 percent (Table 7~. This same period
witnessed the emergence of two new categories of health professionals--
nurse practitioners (NPs) and physician assistants (PAs).
267
OCR for page 268
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OCR for page 269
The first PA program was started in 1966 at Duke University. The
role envisioned for the PA was aiding in many of the primary care
responsibilities that burdened the already overworked physician and
substituting f or physicians in shortage areas .10 The f irst NP
training program was introduced at the University of Colorado at about
the same time to give pediatric nurses expanded clinical training for
primary health care of children. Subsequent programs across the
country prepared family nurse practitioners to meet the primary health
needs of all age groups, geriatric nurse practitioners to care for the
elderly, and certified nurse midwives to care for low-risk pregnant
women. 11
As of 1980, there were more than 1,272,000 active RNs in the U.S.,
approximately 17, 000 NPs and nurse midwives, and an estimated 8, 800
active PAs (Table 7 ~ .
In many cases the services of nonphysician providers overlap those
of physicians. Their work is not only auxiliary to that provided by
the physician, but sometimes i t substitutes for care otherwise
provided by physicians . Increasingly, nonphysician providers and
physicians are competing against each other for patient care
services. For this reason, any comprehensive consideration of
physician manpower must be integrated with manpower assessments of all
other health professionals.
Difficulty of Estimating Requirements for Health Professionals
Although manpower forecasting methods have become more
sophisticated, improvements have been offset by a greater complexity
of the manpower situation and a rapidly changing health care system.
Long-term pro Sections are dependent on social, economic, and political
assumptions based on "most-likely" scenarios in a rapidly changing
health care system. Although total manpower supply figurer can be
projected with reasonable accuracy, predicting requirements for health
services is much more problematic. Ultimately, it is the future
relationship between supply and requirement that will determine
whether there will be an overall shortage or surplus of health
professionals.
There have been noteworthy efforts to project national
requirements for physician services. The most ambitious to date is
the GMENAC requirements model.l2,13 The projections attempt to
estimate the number of physicians needed to provide all medically
necessary and appropriate services for the U.S. population in 1990 and
2000.
The estimates were derived using an "adjusted-needs" model.
Panels of experts examined current patterns of utilization, the
incidence/ prevalence of disease, and norms of care. Using 1978
baseline data, estimates were then made of the changes in utilization
for 1990 that would result from changes in the population and
incidence/prevalence rates. Estimates of medically necessary and
269
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appropriate services for 1990, including well care, reflect
professional medical judgment modified by an assessment of what
realistically can be accomplished by that year.
After obtaining estimates of appropriate utilization, requirements
for physicians were estimated by assessing how much of total service
requirements can be delegated to nonphysician providers, and by
considering the productivity of full-time practicing physicians.
GMENAC projected a need for a total of 466,000 physicians by the
year 1990; the estimated supply was 536,000 indicating an overall
surplus of 70,000 physicians. GMENAC projected a surplus of 145,000
physicians by 2000.
The BHPr's 1982 projections indicate much higher physician
requirements for 1990--570,200--22 percent higher than the GMENAC
estimate. This is largely because the BEPr's projection was based on
demand rather than on need--two distinct concepts. Future need for
health professionals is estimated by the incidence/prevalence
of various illnesses requiring medical treatment; future need considers
what ought to be consumed for the population to stay healthy. Demand
involves the use of medical services largely as an economic decision.
The BHPr requirements model assumes that there will be a
continuing increase in per capita utilization of medical services,
apart from any demographic changes and price changes.1 The
rationale was that long and sustained growth patterns and trends in
any dynamic phenomena rarely stop abruptly, and that it would be
unrealistic to assume that no further growth in per capita consumption
of health care will occur (even though decreases may occur for short
periods of time).
Some analysts concur with the view that the demand for physicians
and their services will continue to increase over the next decade,
partially absorbing the increases in supply. Sloan and Schwartz
predict that during the 1980s, real payments to physicians will
increase by some $14 billion to $20 billion (1979 dollars),
representing increases not only in population but also in payments per
capita population.l4 About one-fifth of the increase will be
attributable to growth in the supply of physicians.
With the current system of third-party reimbursement, it is
possible that levels of demand will exceed "need." Alternatively,
with pressures to reduce federal and state-financed programs,
utilization of health services for some groups may be lower than that
considered necessary and appropriate. To date, many cost containment
mechanisms have been proposed, but relatively few effective ones have
actually been implemented. Effective cost containment would cause per
capita consumption of medical services to fall.
There is some evidence that the current economic recession has
reduced utilization of medical care in some areas, but these
developments may be transitory. In Detroit, for example, declining
270
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health insurance coverage among those who are unemployed has resulted
in a substantial decline in ambulatory visits. Area doctors reported
recently that patient visits declined as much as 30 percent during the
course of a year's time.l5 Nationally, the average number of
patient visits per week for physicians dropped only 1 percent between
1981 and 1982 from 132.6 to 130.9,* despite the recession and
increased numbers of practicing physicians.16
Changes in physician reimbursement policies have the potential to
radically alter present patterns of utilization. Reimbursement
mechanisms can influence the mix of services provided by practicing
physicians in various specialties, hospitals' demand for residents,
and specialty and practice location of young physicians.17 However,
changes in reimbursement are difficult to predict, and any large-scale
change in the current system will certainly encounter political
opposition.
Nonphysician health care providers
According to data from the AMA Socioeconomic Monitoring System,
NPs and PAs working in physician's offices increase physician
productivity about 20 percent. In 1981, there were 3.9 vs. 3.2
patient visits per week respectively for physicians who did vs. did
not employ NPs and PAs.18
Further uncertainty is related to the share of health care
services that would be assumed by the growing number of health care
providers in competition with physicians, e.g., nurse midwives
competing with obstetricians, NPs with primary care physicians,
psychologists with psychiatrists, optometrists with ophthalmologists,
and so forth. Traditionally, physicians have been able to maintain
their professional and economic position in competition with other
groups .
Women Physicians
In 1981, 12 percent of American physicians were women, 19 and
women were 31 percent of the entering classes in U.S. medical
schools.20 It is expected that they will be 16 and 20 percent of
the total pool of physicians by 1990 and 2000, respectively.]
*Caution in interpretation is necessary, since these numbers derive
from a new methodology (telephone survey) which still is being
refined. The data are internally consistent from quarter to quarter,
but are not comparable to mail survey data used previously, which show
a ten-year decline in patient visits per week (see Table 9~.
271
OCR for page 275
the broadest services at the lowest price. Some physician groups have
entered the competition by establishing a variety of organizational
structures and numerous cost-saving arrangements. These include HMOs,
IPAs (independent practice associations) and PPOs (preferred provider
organizations--which offer services at a cut rate to selected employee
groups). The underwriter-provider plans compete with each other by
of fering dif ferent arrays of coverage, deductibles, co-insurance,
limit s, premiums, physician groups, and hospitals .
If physicians are willing to staff these plans on a large scale,
one might envision the incorporation of the health services system.
Employers, facing increased pressures to reduce costs, will negotiate
with employees for the lowest acceptable health payment package.
Employers and government agencies on behalf of employees, retirees,
the poor, and others will in turn negotiate with underwriting
companies, physicians groups, and hospitals for specified services on
the basis of a prearranged annual fee. In each case, rules would
govern the operation, many of them designed to reduce utilization and
costs. Physicians and physician groups that commit themselves to
restraint in the utilization of health services would be in demand by
underwriters and employers. Algorithms, agreed upon in advance, would
determine the specifics of medical care. All of these cost-saving
measures, if effective, would tend to reduce requirements for
personnel.
Although an incorporated health services system is intended to
manage the business aspects of health care, the result could have a
profound effect on the individual interaction between one doctor and
one patient, and on the characteristics of the patient's personal
health services. Individual patient and individual physician
discretion would be reduced under these circumstances. But the
realization of this incorporated structure cannot occur without the
willingness of physicians to staff these plans in large numbers. The
new physicians who are hired will have to abandon professional freedom
in the economic sense and accept the restrictions of incorporated
employment.
Some Results of an Increasing Supply of Physicians
As discussed above, the number of actively practicing physicians
will be increasing sharply in the 1980s. The increasing supply of
physicians is already being felt by young residents in training as
they search for a place to practice. They are finding many areas
already saturated with physicians, the competition for patients very
high, and many hospitals unwilling to accept additional doctors on the
medical staff.
One result is the increasing favor with which new physicians look
upon salaried positions, or assured practices, within an incorporated
structure as provided in HMOs; large multispecialty group practices;
in hospital ambulatory, emergency, critical care, and subspecialty
procedure facilities; with manufacturing concerns; in the military
275
OCR for page 276
system and Veterans Administration; and in other public
institutions .30 The influx of newly trained physicians into
has been so brisk in the past years, and will be sustained at such
high rates through the 1980s, that of all the physicians in practice
in 1990, about 40 percent will have entered practice since 1978 e
practice
such
The effects of the rislog number of physicians and of their
changing attitudes toward employment are evident. Almost 50 percent
of all physicians now derive some of their income from salary. The
Physician Practice Study documented that institutional practice was
the main practice for 15 percent of newly trained family physicians,
42 percent of primary-care-track general internists, 23 percent of
general internists, and 31 percent of subspecialty internists.30
A likely scenario follows. The rapid rise in the number of
physicians will provide the f inal impetus to complete the
incorporation of health services. The negotiations for health
services will be conducted in a buying-selling-servicing mode as in
most markets. Like service contracts for automobiles, office
machines, and home appliances, the allowable services will be agreed
upon in detail in advance. An elaborate set of rules governing
physician decisions will be adopted by each physician corporation.
These rules will specify the allowable use of certain diagnostic tests
f or a given set of symptoms; number of visits per year for a given
condition; components of the annual physical exam; alternatives to
elective surgery; criteria for hospitalization; duration of
hospitalization; allowable drugs ; limits to therapy of the seriously
or terminally ill; the use of preventative, rehabilitative, mental
health, and nursing home services; and most other decisions previously
delegated by society to an individual physician's judgment in an
individual doctor-patient relationship. The ma jor underlying emphasis
of the rule making will be on cost reduction.
There will be decisions on which health professionals will provide
primary care. In adult medical care, for example, roles will be
decided upon for family physicians, general internists, subspecialty
internists, obstetrician-gynecologists, and nurse practitioners, for
psychiatrists, psychologists' and psychiatric social workers. These
sets of rules will in the future make possible a more precise
specification of the relative number of generalists, specialists and
subspeclalists needed.
Many of the changer in the health care system described above have
implications for manpower requirements. The growth of ~Os and other
prepaid plans, the trend of physicians deco select more salaried
positions, and the rule making aimed at cost reduction, for example,
are expected to lower requirements. These changes will tend to
diminish the open-endedness of the market for medical services.
Institutions will establish the number of physicians that can be
efficiently employed. While the total effect of a transformed health
care system on supply and requirements cannot be predicted with
certainty, it would be advantageous to both the institutions that
train physicians and the residents in training to have available
timely information on changing requirements and employment patterns.
276
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Need for Development of a National Bealth-Manpower Policy
Our implicit national health policy has as its objective the
provision of high-quality health services for all Americans at a
reasonable cost to the individual and to society. There is
disagreement, however, about the preferred mechanism for adjusting the
supply of health professional workers.
There are several desirable features of health-manpower planning:
it enables one to plan for the number of slots in medical, osteopathic,
nursing, and other health professions Schools and research training
programs; to plan a program of training that most closely matches
specialty needs; and to make decisions on immigration and licensing.
Conversely, there are drawbacks to national planning. First,
there is a lengthy pipeline in training, especially for the
physician. Changes in numbers of students at the entry level will not
be reflected in the new M.D.s entering practice until seven or more
years later. Policymakers must therefore have approximately a 10-year
vision of health manpower needs.
Second, the vision or forecasts of future need or demand may turn
out to be wrong. Past forecasting attempts have had mixed results, as
indicated in Table 8. Two sets of projections prepared independently
in the same year have dif fered by as much as 15 percent . The 1967
projections of requirements for 1975 provides an example. While
TABLF 8 Comparison of Pro Jections of Physlelan Supply and Requirements f or 195~'
and 1975 Estimated Estimated Actual
Study Requirements Supply Supply
Projections for 1960
Ewing Report (1948)
Mount i n-Penne 1 -Be rge r ( 194 9 )
Presldent's Commission on Health
Needs of the Natloc (1953)
Pro jectlons for 1975
Bane Committee (1959)
Fein (1967 )
Na t tonal Advisory Commlesion
on Bealth Manpower (1967)
1' ~ Pohl in Health Ser~lce (196? )
254,000 212,000 248,66'
233, 532-261, 172 216, 119 248, 664
216 ,000-281, 000 222,000 248, 664
330,000 (minimum) 312,800-318,400 367,000
340 000-38S,000 361,700 367,000
346 000 (alnieum) 360,000 36?, 000
~ 400, 000 - 425, 000 360, 000 367, 000
SOURCE: American Medical "sociatlon.
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agreeing on estimates of supply, the National Advisory Commission on
Health Manpower estimated that supply would exceed requirements and
the U.S. Public Health Service projected that supply would be
substantially lower than requirements. Even from the vantage point of
1983, we can not examine requirements for 1975 retrospectively, in
order to assess the adequacy of the pro Jection methodologies, because
there is no agreed no agreed on standard for determining requirements.
Another possible drawback of national planning is the tendency to
develop policy that overlooks the need for modulation of policy--to
accommodate particular needs derived from distribution problems, for
example.
Some would argue that market forces rather than explicit national
policy should be relied on to make adjustments in enrollments, supply,
and distribution. The marketplace model would restructure the health
care system along lines that would make it price-competitive; that is,
consumers of heath care would base their decisions in large part on
price, a phenomenon that is rare today given the prevalence of a
third-party reimbursement system that obscures cost considerations.31
There are indications that market factors might be working for
physicians. By using market definitions, a decline in real income
indicates that supply has risen faster than demand. Net earnings for
physicians have barely kept pace with inflation, and both practice
hours and patient visits per week have declined (Table 9~.* The
decline in average office visits has occurred in both metropolitan and
nonmetropolitan areas.32 Board certified Dhv~ician`: have tended to
move to smaller previously unserved communities.33~34 Marketplace
proponents argue that with an increased supply of medical manpower,
physicians will make adjustments in location, specialty, and setting.
TABLE 9 Trends in Hours of Work, Patient Visits, and Visits per
_ _
MD practice hours
Year per week
Patient visits Visits
per week per hour
1970
1971
1973
1974
1975
1976
1978
1979
1980
51.4
53.6
50.8
49.9
51.8
52.2
50.3
49.7
49.6
132.5
135.8
137.7
125.8
126.5
128.5
130.6
122.7
112.0
2.58
2.53
2.71
2.52
2.44
2.46
2.60
2.47
2.26
SOURCE: Table IV-14, Reference $1.
interpretation is complicated by the increased numbers of female
physicians, who--on average--practice fewer hours and earn less money
per hour than male physicians. This may reflect the market, it may be
by choice, or be due to some other factor.
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We conclude that a health~manpower policy* is critically important
for long-range funding of medical, nursing, and other health
professional schools and teaching hospitals; for providing reliable
information to high school and college students concerning
opportunities in the health professions; and for providing useful
information for long-range planning of the health services industry.
The aim is to effect and inform both individual and institutional
decisions at a time of rapid change.
Recommendation for a Study
Establishment of a National Health Manpower policy requires a
sustained illumination of the issues through data collection and
analysis, integration across all health professions , ef fective
participation by both the private sector and governments, and the
development of consensus.
Market signals alone cannot be relied on to ad just health~anpower
resources satisfactorily. On the other hand, stop-and-go policies of
expansion/contraction are thoroughly undesirable. Therefore, we
recommend that there be a continuing effort to collect and analyze
data, prepare biennial profiles of the supply and requirements for
health services, issue five and ten year forecasts, and develop
long-tenm health manpower policies and recommendations. This effort
would involve a careful consideration of the rapidly changing health
care system and the consequences of those changes for health
manpower. It would be necessary to integrate manpower needs across
all the professions, including allopathic and osteopathic physicians,
nurses and nurse practitioners, optometrists, podiatrists,
psychologists, and others. Ultimately, the long-tenm requirements for
each profession's services would have to be translated into the number
of available training positions (residencies in each specialty, for
example). Connections should be made between specialty-specific
requirements, supply, training positions, entering class size, and
immigration laws. Especially challenging will be the development of
an acceptable policy for funding medical and graduate medical
education in the approaching era in which the economics of the health
services system will undergo radical transformation.
In addition, it would be desirable to bring the data into
consideration with a number of broad socioeconomic-political issues,
such as: How can the reimbursement system or other mechanism be used
to bring demand for services in line with need? Along the spectrum of
utilization rates (from low to high), where is the maximum benefit in
terms of patient health and function? What is the outcome of health
services as measured in socially relevant terms, i.e., the functioning
of the patients and their productivity? What are the special needs of
certain populations--blacks and Hispanics, the urban and rural poor,
and the elderly? What are the appropriate roles for government?
*Considering, in a coordinated way, loan and scholarship programs;
reimbursement policy; grants to schools for research, educational, and
other programs; FMG visas, and licensure, for example.
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It should be emphasized that while a national policy is desirable,
there is no one body controlling it, given that ours is a decentralized
system. State-controlled institutions comprise 60 percent of the
nation's medical schools. -State legislatures, facing increased
budgetary pressures, will want guidance on future levels of medical
and other health professional school enrollments. States will need to
determine their health-manpower needs, the distribution of existing
providers by location and specialty, the inflow and outflow of health
professionals, and the return rates on funds for health professions
training.35 As they do, they will be greatly assisted by having
available national data f or purposes of compari son.
Specialty societies will also want to compare their assessments
with national statistics. The American Board of Medical Specialties
(ABMs) recently released the following statement: "The ABMS believes
that a continuing study of physician manpower should be conducted.
Directed toward fact-finding and dissemination of information, this
study should be primarily the responsibility of the private sector
with the collaboration and assistance of the federal government."23
The development and successful implementation of a national health
manpower policy would require that a broad constituency be involved
from the outset. This should include medical schools and other health
professions schools, professional organizations, underwriting
organizations, as well as state and federal governments. A national
health-manpower policy can only be implemented successfully through
broad consensus developed by all sectors that have a role to play.
Proposed Study
The structure we are recommending will be referred to as the
National Health Manpower Study and Policy Development Committee (or
the Study). The intent is to develop a continuing, comprehensive,
long-term health~manpower program, although in this document only a
three-year proposal is being presented. A major report on this first
phase of the study would be issued three years after inception of the
Study, which could use 1982 baseline data. The Study would employ
state-of-the-art manpower methodologies; newer modifications should be
introduced to advance the field. Supply and requirements figures
would be calculated for five-year intervals 1987, 1992, and 1997.
Every effort would be made to assess the data for regional, state, and
local areas, not only at the national (aggregate) level.
Development of scenarios that integrate manpower supply with
demand and need would be particularly instructive. One function of
the Study would be to construct the scenarios, and to identify data
needs and methods to collect that data.
It is recommended that the Study have two structural
subcomponents: the staff, whose function would be to collect and
analyze data; and the committee, whose function would be to interpret
the information, weigh alternatives, formulate policy recommendations,
and move toward national consensus.
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The Comit tee would be composed of 20 to 30 individuals, drawn
from a broad constituency~~.edical schools, nursing schools, schools
of public health, and other health professions schools; professional
organizations; unterwritlog organizations; health economists;
political scieneiste; public administratore; state and federal
governments; consumers; and others. The chair would be expected to
spend about one-fourth-time on the endeavor.
The staff would be capable of primary data collection, either
in-house or by subcontract, and sophisticated analyses. The staff
also would take advantage of data collection activities of government
and private agencies (BHPr, AAblC, AANC, AMA, etc. ). The staff
director would be a senior, experienced, and professionally respected
individual. A stat f of approximately 10 full-time equivalents is
envisioned, including an administrative director, senior analysts,
statisticians, economists, data-management personnel, and secretaries.
The committee might meet quarterly for two days at a time.
Subcommittees or task forces could be organized for specific
assignments, each with a staff person. A preliminary report should be
prepared by the end of the first 18 months and be widely circulated
for comment and criticism. A series of regional conferences should be
held at various locations, actively involving in the process state and
federal representatives an well as all other interested parties. The
ob jective would be to reach broadly toward all concerned and to
develop a broad consensus. A major report should be issued at the end
of the three-year period.
Home f or the Study
There are several possible homes for such a project. Wlthln the
federal government, the Bureau of Health Professtons of the Department
of Health and Human Services has a mandate to report to the President
and Congress on the status of health professions personnel in the
United States. The Barr has a great deal of experience collecting ant
analyzing such data. In developing manpower policy, however, the
federal government would be necessarily tied to political concerns.
Both the American Medical Associatlon and the Association of
American Medical Colleges have been actively involved in manpower data
collection, assessments, and policies. Neither group is, however,
explicitly concerned with health professionals other than M.D.s. The
AMA ant the ALEC are also Grieved as looking predominantly at the needs
of the profession, although the needs of the public are also high on
their agendas. In . Determining requirements f or health professionals
in particular, it is important that the work be carried out on a
neutral level, drawing together the views of all sectors.
The Institute of Medicine, which can bring together many disparate
interests, is in a good position to provide leadership. Its elected
membership spans a broad range of the health professions and includes
health policy analysts from the fields of law, economics, and public
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a/ministration. The. Institute of Medicine Committee on National Needs
f or Biomedical and Behavioral Research Personnel could provide
extensive data and analyses for research manpower policy formulation.
We believe that the Institute can provide the needed connection
between manpower planning and health professions education.
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285
Representative terms from entire chapter:
medical schools
