AAMC Reporter: May 2009

Physician Workforce Experts See Opportunity in Reform

As the nation begins to get serious about health care reform, many are beginning to realize that increased health access will probably require additional physicians and other health professionals. Understanding physician workforce needs in the larger context of health care reform was the main theme of the AAMC's recent Physician Workforce Research Conference.

"The recession is slowing demand for physicians, but health care reform will increase it," said Edward S. Salsberg, director of the AAMC Center for Workforce Studies. "Building the infrastructure for a reformed health care system includes assuring an adequate physician workforce over the long run. This is a time of great challenge and opportunity for the nation and for physician workforce planners.

The concern that physician shortages could impede reform is consistent with findings from recent Center for Workforce Studies analysis. A projected enrollment increase of 6,000 medical and osteopathic school between 2002 and 2013 would not be enough to ameliorate the estimated shortage of as many as 100,000 physicians or more in the coming years, according to center data. Furthermore, enrollment increases will not lead to net increases in the physician supply without a corresponding increase in residency training positions, the physician to population ratio would actually begin to drop at a time if increased demand, Salsberg noted.

However, experts stressed that producing more doctors will not improve the system if not combined with improvements in delivery and payment methodologies.

"I don't think we have the luxury of maintaining rigid lines between health care sectors and health care providers," said Mary Wakefield, Ph.D., R.N., newly appointed administrator of the federal Health Resources and Services Administration.

In the conference's keynote address, J. Lloyd Michener, M.D., chairman of the community and family medicine department of Duke University School of Medicine, noted that innovative partnerships have helped some areas of North Carolina streamline their health care system and reduce the demand for physicians, particularly in underserved areas.

"What does it take to have healthy communities, and what can we do with the workforce to help us do that?" Michener said. "We have to figure out what belongs where—what services are best provided by a hospital, what is best provided in practice, and what belongs in the community."

According to Michener, Duke partnered with the Durham parks department, social services agencies, local charities, and other groups to help educate patients about the health care system and provide ancillary assistance such as follow-up home visits for shut-ins. Among program participants in the Durham area, emergency room visits have declined by 25 percent, Michener said.

As far as the health care workforce shortage, Wakefield said the Obama administration recognized the potential severity of the problem, and that HRSA was doing its part via the $2.5 billion it received through the American Recovery and Reinvestment Act (ARRA). The extra funds will ultimately allow HRSA to provide educational debt relief for thousands of new doctors and other health professionals, Wakefield said, along with better data analysis, a streamlined application process for the National Health Service Corps that Wakefield said will "get clinicians into the field much faster," and training in diversity and health informatics.

"We can't stamp out new graduates with an assembly line mentality," Wakefield said. "We have to nurture them in a way that is tailored to their interests and skill sets, and encourage them to serve in areas that most desperately need them."

Workforce experts also recognized ways the national payment system influences physician supply and practice patterns. Two major concerns for workforce planners and reform advocates—a decreasing interest in primary care and an inefficient health care system—seem to be particularly influenced by payment policy. Several possible solutions to increase compensation for primary care services are already on the table in Washington, and include the patient-centered medical home and so-called payment bundling, or a single payment given to multiple providers for an episode of illness. Mark E. Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), suggested bundling Medicare payments based on the health of a local patient population, and potentially including bonuses for meeting quality and cost benchmarks.

"The current payment system does result in fragmented and uncoordinated care," Miller said. "The signal to providers is that they should produce more...but we want to make things more coordinated."

Miller, who stressed that MedPAC has made no formal recommendations on the subject, also said the commission is considering graduate medical education (GME) funding as a means of encouraging delivery system reform and increasing non-hospital experiences during residency. GME funding, Miller said, could even go to individual residency programs rather than hospitals.

While much of the physician shortage discussion centers on primary care, Salsberg acknowledged that many other specialties were also beginning to feel the effects of a workforce shortage.

"Whether it is general surgery, psychiatry, emergency medicine, or oncology," he said, "shortages are already apparent in a wide range of specialties."

Paul Ginsburg, Ph.D., president of the Center for Studying Health System Change, said current Medicare payment policy is resulting in "sharp differences in incomes by specialty," with areas like general surgery that do not frequently perform office-based tests such as MRI exams on the short end.

Ginsburg noted, however, that "re-engineering resources may make certain courses of treatment less profitable" and trigger a backlash among some specialties and providers. A large source of underlying tension in the workforce debate—that increased primary care payments may need to be paid for by reduced payments for other specialty services—remains unresolved.

"That is in need of a lot of attention," said Wakefield in reference to the issue.

—By Scott Harris