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2 U.S. PHYSICIAN SUPPLY AND REQUIREMENTS: MATCH OR MISMATCH?
Pages 23-48

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From page 23...
... Because any analysis of the match or mismatch between supply and requirements calls for complex forecasts of numbers, the chapter also briefly describes common approaches to estimating the present and future supply of physicians and the need or demand for physician services. That discussion is followed by a section on factors that will affect the future requirements for physicians.
From page 24...
... Pre-1980s Era Concerns about a physician shortage dominated national physician workforce policy during the 1950s, 1960s, and early 1970s. As given in government statistics of the time, the number of active nonfederal M.D.
From page 25...
... provided November 1, 1995. 1950 through 1990 data adjusted by BHP from American Medical Association Physician Masterfile and unpublished American Osteopathic Association data.
From page 26...
... A major change in thinking about the adequacy of the U.S. physician workforce came in 1980 with submission of the report of the Graduate Medical Education National Advisory Committee (GMENAC, 1981~.
From page 27...
... Of relevance to the specialty debate are the data that Kindig (1994) presents showing that, in 1992, slightly more than 182,000 active patient care physicians (not including residents and fellows)
From page 28...
... of Physicians per 100,000 Populationa 1970 1980 1992 1970 1980 1992 Total Total Active Physiciansb Total active physicians in patient cares 328,020 462,276 685,291 308,487 436,667 627,723 222,657 310,533 461,405 160.9 203.5 267.5 151.4 192.2 245.0 109.2 136.7 180.1 Total active physicians in other professional activity 31,582 38,009 39,816 15.516.7 15.5 Teaching NA NA 8,293 NANA 3.2 Research NA NA 16,398 NANA 6.4 Administration NA NA 15,125 NANA 5.9 Total physicians in training providing patient cared 50,687 61,450 99,138 24.927.1 38.7 Not classified 3,561 26,675 27,364 1.711.7 10.7 Total Inactive Physicians 19~533 25,609 57,568 9.611.3 22.5 NOTE: NA = not available. ' Data for 1970 and 1980 are for allopathic physicians (M.D.s )
From page 29...
... allopathic and 16 osteopathic medical schools during the 1960s and 1970s contributed considerably to increases in the nation's physician supply. Since the 1980s, however, the number of M.D.
From page 30...
... Thus, the issue of the long-term match between the supply of physicians in this country and the expected requirements for physician services cannot, ultimately, be addressed without consideration of the role of and policies toward IMGs. METHODS OF ESTIMATING PHYSICIAN SUPPLY, PRODUCTIVITY, AND REQUIREMENTS Physician Supply Most analyses of the U.S.
From page 31...
... In plain language, physician productivity is the total number of physician services produced in a year divided by the total number of active physicians in that year.7 The need or demand for physician services or, more precisely, the number of the "full-time-equivalent" (FTE) physicians required to yield that number of physician services is the product of the total population and the per capita use of physician services in a year divided by physician productivity.
From page 32...
... Physician Requirements The term "requirement" is generally used as an umbrella term to encompasses all attempts to measure the need or the demand for physician services. Determining the requirement for physicians or their services involves more judgment and assumptions than does predicting the future physician supply.
From page 33...
... Most important of these would be enactment of legislation to provide universal access to health care services for the estimated 40 million Americans who now lack health insurance. In view of both the failure of the Clinton administration to obtain passage of the Health Security Act and the more recent efforts to reduce federal spending by dramatic levels, the goal of universal access is very unlikely to be attained in the foreseeable future.
From page 34...
... could increase the demand for long-term-care facilities, geriatric nurse practitioners, and other nursing personnel more than the demand for physician services. Furthermore, nearly a half century of biomedical research has yielded much knowledge now ready for clinical evaluation and perhaps application; this may prompt a greater use of physicians as clinical investigators as well as higher employment of physicians in the pharmaceutical and biotechnology industries, although the proportion of physicians in research or employment by such firms is tiny in comparison to the proportion in patient care.
From page 35...
... . Other information, however, suggests that the ratio of patient care physicians to enrollees in "mature HMOs" comes closer to the FFS levels; Dial et al.
From page 36...
... the two-thirds ofthe population enrolled in managed care in the year 2000 will require 171 patient care physicians per 100,000 and (2) the onethird of the population remaining in the FFS sector will require a physician-topopulation ratio of 174 per 100,000.
From page 37...
... Several managed care organizations in Minnesota are experimenting with a process known as "substitution" or "offloading." In an effort to increase efficiency and reduce health care costs, they are allowing health care personnel with lesser amounts of education or training to perform tasks and assume responsibilities traditionally reserved for physicians and other health professionals with longer periods of formal preparation. Registered nurses (RNs)
From page 38...
... supply of physicians per population was smaller than in Belgium and West Germany, about the same as in the Netherlands, and larger than in the United Kingdom. Both Belgium and the Netherlands had officially recognized a physician oversupply (evidence cited included falling physician incomes, physician underemployment or even unemployment, and low morale of those in training)
From page 39...
... Its findings derived from an adjusted need-based approach for determining the requirement for physician services. A decade later, PPRC (1992)
From page 40...
... Using an extrapolation method and assuming that 40 to 65 percent of Americans would receive their health care from integrated managed care networks in the near future and that all citizens would be covered by some form of health insurance, Weiner (1994) predicted that, in the year 2000, the overall surplus of patient care physicians would reach 165,000, a figure representing about 30 percent of all physicians in the patient care category.
From page 41...
... indicated that physician supply and outlays for physician services grew in the 1970s; in addition, gross income of individual physicians increased about 1 percent annually, but real net income for physicians rose only about 1.7 percent over the entire period. Changes in
From page 42...
... A final unknown is whether older, more expert specialists would or would not be more attractive to managed care systems and what effects the employment or contracting practices of these networks would have on physician incomes. In the end analysis, whether trends in physician income can tell us anything useful about the supply of physicians in generalist or specialist practices and about physician preferences for FFS or managed care practice remains unclear.
From page 43...
... CONCLUSION Most studies of the adequacy of the physician workforce for the past 15 years have concluded that the United States has an oversupply of physicians, generally characterized as a large surplus of most nonprimary care specialists and either a shortage or a relative balance in the supply of primary care physicians. Marketplace evidence supporting these findings is at present inconclusive.
From page 44...
... These topics are taken up in the next chapter. NOTES Figures for the supply of physicians in this country can diverge dramatically, depending on whether the data refer to all physicians, all active physicians, all active nonfederal physicians, patient care physicians, or some other grouping.
From page 45...
... schools accredited by the Liaison Committee on Medical Education or the American Osteopathic Association, virtually all of whom are U.S. born, or from similarly accredited Canadian medical schools)
From page 46...
... . integrate the financing and delivery of medical care through contracts with selected physicians and hospitals that provide comprehensive health care services to enrolled members for a fixed predetermined fee." In most people's minds, managed care can include traditional staff- and group-model HOMs, IPAs, and PPOs (which may involve tightly bound arrangements that render them exclusive provider organizations tEPOs]
From page 47...
... indicated that in 1994, 25 percent of people insured were in HMOs, 25 percent in PPOs, 15 percent in POS plans, and only 35 percent in traditional indemnity plans; he also stated that among employed individuals who have a choice between managed care and traditional FFS insurance, the proportion choosing PPOs and POS plans increased between the mid-1980s and 1994. Because cost constraints in PPOs and POS arrangements may be weaker than those in traditional HMOs and EPOs (i.e., they may more closely resemble those operating in the FFS sector)


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