POTENTIAL SOLUTIONS for the EVOLVING PHYSICIAN SHORTAGE

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POTENTIAL SOLUTIONS for the EVOLVING
PHYSICIAN SHORTAGE

• Richard A. Cooper, M.D.
• Florida Board of Governors
• Orlando
• March 17, 2004

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POTENTIAL SOLUTIONS
--------------------------------------------------
-------------------------------------- Expand the
infrastructure for undergraduate medical
education ----------------------------------------
------------------------------------------------ E
xpand the applicant pool -------------------------
--------------------------------------------------
------------- Expand residency (GME) training
programs -----------------------------------------
----------------------------------------------- In
crease the number of International Medical
Graduates ----------------------------------------
------------------------------------------------ I
ncrease the utilization of nonphysician
clinicians ---------------------------------------
-------------------------------------------------
Streamline the processes of care -----------------
--------------------------------------------------
--------------------- Improve the legal and
regulatory environment for medical
practice -----------------------------------------
-----------------------------------------------
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EXPANSION OF MEDICAL SCHOOLS
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MEDICAL SCHOOLS, MATRICULANTS and GRADUATES,
1940-2002Allopathic and Osteopathic
1935-1940 1.0
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CONTRIBUTIONS TO INCREASED NUMBERS OF MD
MATRICULANTS AND GRADUATES, 1960 vs. 1980
15
54
45
46
40
6
DEANS SURVEYEXPANSION CAPACITY OF EXISTING
MEDICAL SCHOOLS
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SATELLITES and BRANCHES
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SATELLITE CAMPUSES
Expand educational capacity of school Distant
from main campus Separate administrative
structure Significant educational components Most
developed in 1960s and 1970s 28 schools with
satellite clinical campuses 6 schools with
satellite preclinical campuses
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BRANCH CAMPUSES
ALLOPATHIC MEDICAL SCHOOLS U of I branch at
Urbana, Rockford, Peoria Cleveland clinic branch
of Case-Western Reserve OSTEOPATHIC MEDICAL
SCHOOLS Touro University (CA) branch at Las
Vegas, NV Philadelphia COM (PA) branch at
Atlanta, GA Lake Erie COM (PA) branch at
Bradenton, FL Western University (CA) branch
planned ? where
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APPLICANTS
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BACHELORS GRADUATES and MEDICAL APPLICANTS
1940-2001

• Medical
• Applicants
• 50,000
• -40,000
• -30,000
• -20,000
• -10,000
• - 0

NCES/AAMC
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BACHELORS DEGREES 1920 to 2000
Vietnam Draft 1M (14) of the 7M men who
attended college during the Vietnam
draft 1963-1978
GI Bill 2.0M of the 3.4M who attended
institutions of higher education under the GI
Bill 1945-1965
NCES, Table 171
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FIRST-TIME ALLOPATHIC MEDICAL SCHOOL
APPLICANTSas a PERCENTAGE of BACCALAUREATE
DEGREES1961-2001
AAMC/NCES
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WHITE MALEBACHELORS DEGREES AND FIRST-TIME
MEDICAL APPLICANTS1977-2000
15
WHITE FEMALEBACHELORS DEGREES AND FIRST-TIME
MEDICAL APPLICANTS1977-2000
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ASIANBACHELORS DEGREES AND FIRST-TIME MEDICAL
APPLICANTS1977-2000
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BLACKBACHELORS DEGREES AND FIRST-TIME MEDICAL
APPLICANTS1977-2000
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STUDENTS MUST GRADUATE FROM HIGH SCHOOL TO GO
TO COLLEGE .BUT EVEN THEN, THEY MIGHT NOT
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HIGH SCHOOL COMPLETERS 1967-2000
Census Bureau Table A-5
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BACHELORS DEGREES PER CAPITAPer 1,000 21-year
olds
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RELATIVE PROPORTIONS of WHITES, ASIANS, BLACKS
and HISPANICSVARIOUS LEVELS OF EDUCATION,
1999-2000
Bureau of the Census, NCES, AAMC
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BACHELORS GRADUATES 1961-2001 and projected to
2012
Projected
NCES
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FIRST-TIME MD APPLICANTS1961-2001 and
extrapolated to 2020Smoothed Trend
Sufficient for 5,000 additional medical school
acceptances at the margin
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1. Creating sufficient numbers of high quality
positions.2. Limitations of Balanced Budget
Act of 1997 Positions frozen at 1996
levels.3. Budget implications of additional
positions Each new PGY-1 position will obligate
Medicare to 35,000 in DME payments per year
for an average of 4.5 years). 5,000
positions 800M If IME payments are also
allowed, each new first year position will
obligate Medicare to an additional 75,000 for
4.5 years. 5,000 positions 1.5B Total
increase in Medicare GME at current rates would
be 5,000 positions 2.3B
GME CHALLENGES ----------------------------------
--
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INTERNATIONAL MEDICAL GRADUATES
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IMGs(all years)Citizenship or Visa Status
Corrected for unknown
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NON-US IMGsIndia, No Africa, Middle East vs the
Rest of the World
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ConcernsUS-IMGs vs. Foreign IMGsQuality of
educational programsRate of disciplinary
actionsHurdlesUSMLE Steps 1, 2, 3Clinical
Skills Assessment (CSA) (cost, time)Visas to
take CSA examVisas to enter for
residencyDecreased availability of H1b
visas (195K in 2003 ? 65K in 2004)CompetitionE
nglandCanadaAttractiveness of native countries
IMG CHALLENGES
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POTENTIALS and LIMITATIONS ofNONPHYSICIAN
CLINICIANS
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OVERLAPPING RESPONSIBILITIES OFPHYSICIANS AND
NONPHYSICIAN CLINICIANS

• COMPLEX CARE
• MULTISYSTEM DISEASE CARE
• CHRONIC DISEASE MANAGEMENT
• MINOR and SELF-LIMITED DISORDERS
• SYMPTOM CONTROL
• WELLNESS CARE and PREVENTION
• COUNSELING and EDUCATION

PHYSICIANS
NONPHYSICIAN CLINICIANS
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PROCESSES of CAREBetter information
managementStreamlined flow of careSafer
technologiesvs. Onerous federal
regulationIntrusive managed care review
Crippling malpractice litigation (Tort reform)
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TIME FRAME OF POTENTIAL IMPACT
--------------------------------------------------
-------------------------------------- 10-15
Expand the infrastructure for undergraduate
medical education --------------------------------
--------------------------------------------------
------ 10-15 Expand the applicant pool
-------------------------------------------------
--------------------------------------- 5-10
Expand residency (GME) training
programs -----------------------------------------
----------------------------------------------- 5-
10 Increase the number of International
Medical Graduates --------------------------------
--------------------------------------------------
------ 5-10 Increase the utilization of
nonphysician clinicians --------------------------
--------------------------------------------------
------------ Now Streamline the processes of
care ---------------------------------------------
------------------------------------------- Now
Improve the legal and regulatory environment for
medical practice ---------------------------------
--------------------------------------------------
-----
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• RECOMMENDATIONS
• _______________________________________________
  
• Begin immediately to expand the
  infrastructure for undergraduate
  medical education.
• Expand residency training opportunities,
  especially in the non-primary care
  specialties.
• Foster continued development of
  opportunities for NPs and other NPCs,
  particularly in primary care.
• Examine the global impact of a continued
  dependence on IMGs.
• Review the factors that affect practice
  efficiency and professional satisfaction
  among physicians.

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• Thank you.

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