The Nation's Physician Workforce Options for Balancing Supply and Requirements (1996) / Chapter Skim
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3 RELATIONSHIP OF PHYSICIAN SUPPLY TO KEY ELEMENTS OF THE HEALTH CARE SYSTEM
3 RELATIONSHIP OF PHYSICIAN SUPPLY TO KEY ELEMENTS OF THE HEALTH CARE SYSTEM
Pages 49-74
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From page 49... ...
The tendency has been to believe that simply adding more and more physicians to the country's present stock will go a long way toward meeting these goals and that doing so would have few, if any, serious negative ramifications. Chapter 2 presents solid evidence that the United States has succeeded dramatically in increasing its supply of physicians to a level that some, but not all, on the committee characterized as a surplus and that if an oversupply does not now exist, it will at some future date given current trends in training and utilization.
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From page 50... ...
HEALTH CARE EXPENDITURES Using standard models of microeconomic theory, one might expect that a significant increase in the number of physicians would increase competition, produce lower incomes for physicians, and reduce health care costs. Theory, however, is not entirely or consistently borne out in practice.
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From page 51... ...
is tenuous at best, especially In a health care environment undergoing the many changes in organization and specialty distribution occurring in this nation. No clear evidence exists that an excess of physicians is driving their net incomes down to any significant degree; even if an oversupply did have a dampening effect on incomes, this might not translate into direct, significant dollar savings in the nation's overall health care spending.
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From page 52... ...
In general, one can conclude that a health care system heavily dominated by a small number of large managed care entities will, all other things equal, not be affected by a physician surplus in the way a FFSoriented system is. In fact, an oversupply of physicians in a world dominated by managed care catalyzes the cost-constraining effects of managed care, quite apart from the number of services that physicians order or provide.
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From page 53... ...
in managed care entities is not clearly consistent with expanding access to care across all groups in the country. Physician supply and access issues are often examined in terms of two areas of"distribution"-geography and specialty.
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From page 54... ...
Indeed, the most recent data from the Council on Graduate Medical Education (COGME, 1995) show that the geographic maldistribution (e.g., for counties of fewer than 50?
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From page 55... ...
Although a greater supply of physicians has helped improve access to specialists in smaller communities, it has not completely solved the problem or corrected perceived imbalances in supply across geographic regions. However, access difficulties probably never were, and never will be, wholly amenable to resolution through increased "supply" when significant financial and nonfinancial barriers to seeking care continue to exist.
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From page 56... ...
As with geographic maldistribution, the infusion of large numbers of IMGs did not, and in the future will not, help resolve specialty imbalances because IMGs subspecialize as frequently as USMGs; only about one-third of both USMGs and IMGs in patient care elect primary care specialties of general or family practice, pediatrics, and internal medicine (Mullen et al., 19954. The complicating factor is that the "pipeline" of physicians in these fields that is, the numbers entering into or presently in training is quite long.
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From page 57... ...
As managed care approaches to the organization and financing of health care diffuse across the country, the possibility of an even greater surplus of physicians cannot be dismissed, and the existence of many more physicians than appear to be required may do little to redress serious problems of access to care in the nation as a whole. QUALITY OF CARE According to a 1990 Institute of Medicine (IOM)
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From page 58... ...
As implied in the discussion of expenditures, a significant physician oversupply would pose potential harms to patients from unnecessary care (Perrin and Valvona, 1986) , especially in the FFS sector.
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From page 59... ...
However, because of the uncertain balance between managed care and FFS arrangements in coming years and the very different effects those approaches have on volume of services the net impact of a physician surplus on volume of services, and hence on quality of care, cannot be foretold with any certainty. Provider and Consumer Satisfaction Another, less-well-appreciated potential effect involves physician and public attitudes but the net impact of large numbers of physicians is not simple to
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From page 60... ...
Specialist-Generalist Issues The question of specialist-generalist balance in the supply of physicians in this country may be especially pertinent to quality-of-care issues (Schwartz, 1994~.~° For high-quality care overall, experts appear to agree that an appropriate physician workforce needs both generalist physicians managing routine health care needs (either alone or coordinated with Ups or PAs) and a balanced supply of specialists to deal with illnesses requiring expertise in addition to that of the generalist (Greer et al., 19943.
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From page 61... ...
To the degree that this is true, a physician surplus has no easily predicted influence on the specialtyprimary care patterns in this country and, thus, no easily anticipated effect on this element of quality of care. Education and Training Other quality-of-care issues concern physician training and education.
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From page 62... ...
It does, however, take note of the growing view of other observers that graduate medical education (GME) must be broadened considerably (Pew Health Professions Commission, 1995a)
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From page 63... ...
Furthermore, certain other indicators, such as infant mortality and teenage pregnancy rates, may be related more to social ills than to poor or inaccessible health care, and "more" health care directed at these problems may be of comparatively marginal value. Summary Comment In the end, this committee viewed the likely effect of a physician surplus on quality of health care as indeterminate on average, although data cited earlier with respect to certain specialties and volume-outcome relationships clearly point to problems that might arise with excess numbers of physicians.
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From page 64... ...
The policy question is whether the investments that they, their families, and the nation will make in such education will pay off for them and for society as a whole. Unlike a graduate degree in law or business administration, medical education is not of great use as a "foundational" degree.
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From page 65... ...
One option sometimes suggested for trimming the output of physicians in this country is to reduce the number of individuals in undergraduate training, either by closing medical schools or by reducing class sizes. However, the demand for graduates to fill residency slots remains high, and as noted in Chapter 2, the excess demand is filled with IMGs currently about 7,000 or more residency positions a year because the production of M.D.s and D.O.s (about 17,500 per year)
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From page 66... ...
Future of Academic Health Centers General Issues Threats to academic health centers. In its July 1995 meeting, the committee discussed at some length the concerns of several of its members about the future of academic health centers (AHCs)
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From page 67... ...
A significant FFS presence might foster the current configuration of AHCs, whereas a predominant managed care orientation might well undermine it, especially to the extent that managed care enterprises opt to create their own residency or graduate training programs to suit their particular norms and ways of organizing health care delivery. Although the committee did not have time to explore these issues in any depth, it did choose to go on record as concerned about this vital element of the nation's health care system '5 The challenge is to balance the size and
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From page 68... ...
are called for to achieve a good balance is a matter for further debate (see Chapter 44. The Service-Training Link and IMG-Dependent Institutions An additional complexity is the long-standing federal policy that connects payments for graduate medical education that is, residency training to service and patient care.
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From page 69... ...
Some in the health field argue that this level of service from residents, whether U.S. or foreign trained, is essential to the provision of inpatient care in underserved areas or for vulnerable populations such as those in inner cities or rural communities.
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From page 70... ...
Generally, it is not possible to demonstrate that too many physicians will improve the quality of patient care; indeed, if the surplus is made up largely of IMGs, it may dilute quality. In addition, a surplus will contribute to higher aggregate health care costs at least as long as the nation has a significant FFS sector.
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From page 71... ...
5. In some urban areas, large academic health centers operate community health centers, school clinics, and the like through various types of ambulatory care networks aimed at the poor sections of metropolitan areas.
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From page 72... ...
whether the essential characteristics of an "American' physician are forged in residency training or in college and undergraduate medical education (if not earlier)
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From page 73... ...
analysis was confined to hospitals with residency programs in six specialties and to those that are potentially dependent on resident IMG physicians to provide basic medical care services to the poor. Under these restrictions, the analysis reduced to 688 of the nation's hospitals; 77 of these met all of the authors' conditions for being IMG dependent and providing care to a significant proportion of poor patients.
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