Physicians

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Active Physicians per 100,000 ofPopulation4003503002502001501929TREND MODELPhysicians per capita and GDP1975 2000100$0 $10,000 $20,000 $30,000 $40,000 $50,000GDP per Capita (1996 dollars)2020-25 Projected Supply


Active Physicians per 100,000 ofPopulation4003503002502001501929TREND MODELPhysicians per capita and GDP1975 2000Physician ageWomen physicians--------------------------------------------------------Lifestyle, EmploymentNonclinical careersEarly retirementResident hours100$0 $10,000 $20,000 $30,000 $40,000 $50,000GDP per Capita (1996 dollars)2020-25 Projected SupplyEffective Supply


Active Physicians per 100,000 ofPopulation40035030025020015010019291975 YOU ARE HERE2000$0 $10,000 $20,000 $30,000 $40,000 $50,000GDP per Capita (1996 dollars)Demand DemandSupply20% gap


SPECIALTIES WITH GREATEST CURRENT SHORTAGESAllergy and ImmunologyDermatologyCardiologyEmergency medicineEndocrinologyGastroenterologyGeneral surgeryGeriatricsNeurosurgeryNeurologyOrthopedicsOncologyPediatric sub-specialtiesspecialtiesPulmonary/Critical CarePsychiatryUrologyRadiologyInternal MedicineFamily Practice


PHYSICIAN SHORTAGES REPORTED FROM THE STATESArizonaCaliforniaGeorgiaKentuckyMassachusettsMichiganMississippiNevadaNorth CarolinaOregonTexasWisconsin


THE REALITY: 2008THERE WERE TOO FEW SPECIALISTSandTOO FEW PRIMARY CARE PHYSICIANSTHERE WERE TOO FEW MEDICAL SCHOOLSandTOO FEW RESIDENCY POSITIONS


Peter Orszag, Director“If we can move our nation toward the practicesof lower-cost areas, health-care costs could bereduced by 30%, about $700 billion a year.”


Physicians and Health Care Reform225%200%Percent175% of1990150%GDP +1.00%HC Exp + 1.50%HC Labor + 1.20%Physicians + 0.75%HC Expenditures =GDP +2.5% +1.0%Demand forPhysician Services▬▬▬▬▬▬▬125%100% Actual Projected 1990 1995 2000 2005 2010 2015 2020 2025Year


225%200%Physicians Supply and Demandunder Health Care ReformDemand▬▬▬▬▬▬▬Percent175% of1990150%Turn of theCentury BulgePhysician SupplyPGY-1+1,000+ 500Nochange125%100% Actual Projected 1990 1995 2000 2005 2010 2015 2020 2025Year


325Physician SupplyPer Capita275225Physiciansper 175100,000of PopulationPhysiciansPGY -1 Residents+1,000+ 500No change125752005 2010 2015 2020 2025Year


325Physicians plusAdvance Practice Nursesand Physician Assistants275225Cliniciansper 175100,000of PopulationPhysiciansPGY -1 Residents+1,000+ 500No change12575APNs and PAs2005 2010 2015 2020 2025YearAPN+PA EnrollmentHigh enrollmentLower enrollment


Physicians plusAdvance Practice Nurses And Physician Assistants325Current enrollmentfor APNs and PAs275225Cliniciansper 175100,000of Population12575Physicians, APNs and PAsPhysiciansAPNs and PAs2005 2010 2015 2020 2025Year+1,000+ 500No changePGY -1 Residents+1,000+ 500No changeAPN+PA EnrollmentHigh enrollmentCurrent trend


Combined Shortages ofPhysicians, APNs and PAs20%No increase in residents15%+ 500 residentsPercent10%Shortages5%0%2005 2010 2015 2020 2025YearCurrent enrollment trends forAPNs and PAs


HEALTH CARE REFORM2010America spends more but gets less.Commonwealth FundStates with more primary care have lower costs andbetter quality.StarfieldRegions with more spending and more specialists have nobetter outcomes – sometimes worse.Wennberg, Fisher, Skinner


Dartmouth Atlas White Paper“Given the apparent inefficiency of physician practices,the nation does not need more physicians.Congress should resist efforts to increase the numberof residency positions funded by Medicare.”


Dartmouth Institute for Health PolicyGetting Past DenialThe High Cost of Health Care in the United States“Some physicians have concluded thatthe reason their hospitals or regions spend moreis that their patients are sicker and poorer.”“Regional differences in poverty explainalmost none of the variation.”Sutherland, Fisher and Skinner, NEJM, Sept 24, 2009


P-O-V-E-R-T-YDoes it matter?


Regional PovertyPoverty, 20000 - 20%20 - 40%40 - 60%60 - 80%80 - 100%


Urban Poverty


ChicagoPer Capita Income = 114% of US AveragePoverty, 20000 - 20%20 - 40%40 - 60%60 - 80%80 - 100%The Bruton CenterThe University of Texas at Dallas


PhiladelphiaIncome = 118% of US AverageThe Bruton CenterThe University of Texas at Dallas


DetroitIncome = 96% of US Average


MilwaukeeIncome = 104% of US Average


600Hospital Utilization in Wisconsin HRRs500Hospital400Daysper1,00030030%Milwaukee HRR200Other Wisconsin HRRs1000day/1000_1864Wisconsin HRRsDays per 1,000Ages 18-64


WEALTH, POVERTY and HOSPITAL UTILIZATION IN MILWAUKEEPoverty Household IncomeHospital DaysMost Lowest Most


Poverty CorridorPoverty Household IncomeHospital DaysMost Lowest Most


Hospital Utilization in Wisconsin HRRs600500Hospital400Daysper1,00030030%MilwaukeePoverty CorridorMilwaukee w/oPoverty Corridor200Other Wisconsin HRRs1000day/1000_1864Wisconsin HRRsDays per 1,000Ages 18-64


AffluencePOVERTY‣Social networks‣EducationPoorHealthStatus MortalityAffluence UnemploymentDemandforCare Hospitals Physicians NursesPooroutcomesReadmissionsEXPENDITURES


MedPAC’sMetropolitan Statistical Areas (MSAs)


MedPAC’s MSAsGeographic Variation in Medicare Expenditures25%20%% ofMSAs15%10%5%0%70-7480-8490-94100-104110-114120-124130-134140-144Medicare, % of National Average% of 401 AK and HI excluded


MedPAC’s MSAsRural North25%20%77% ofMSAs15%10%3245%0%70-7480-8490-94100-104110-114120-124130-134140-144Medicare, % of National Average% of 401 AK and HI excluded


MedPAC’s MSAsSouth25%20%312% ofMSAs15%10%895%0%70-7480-8490-94100-104110-114120-124130-134140-144Medicare, % of National Average% of 401 AK and HI excluded


MedPAC’s MSAsNorth and South vs.The Rest25%20%312% ofMSAs15%10%895%0%70-7480-8490-94100-104110-114120-124130-134140-144Medicare, % of National Average% of 401 AK and HI excluded


The Commonwealth MythThe US spends more but has worse outcomes.250200150100500Deaths per 100,000Commonwealth 2007Preventable MortalityOECD CountriesUSTotalFrance 65Japan 71Australia 71Spain 74Italy 74Canada 77Norway 80Netherlands 82Sweden 82Greece 84Austria 84Germany 90Finland 93New Zealand 96Denmark 101UK 103White BlackAmerica AmericaIreland 103Portugal 104MW-WestNorth EastCA-SWNo CentralSouthSoutherncore


250The International MythMortality in the north is similar to Austria, Germany,and Finland, but mortality in the south is double France.Column 20200150100Preventable MortalityMW-WestNorth EastCA-SWNo Central500Deaths per 100,000Commonwealth 2007OECD CountriesTotalWhite BlackAmerica AmericaSouthSoutherncore


Primary CareStates with more Family Physicians(but not with more General Internists)have lower mortality.High FPLow FP


The Realities of Health Care*************************Geographic variations in health care spending andoutcomes are due principally to geographicdifferences in poverty.The high health care costs associated with povertyare a major factor underlying high health careexpenditures overall.Policy changes made according to geographic normswill harm low-income patients and the providerswho care for them.Failure to train adequate numbers of physicians willharm all patients.


Visithttp://buzcooper.comPHYSICIANS AND HEALTH CARE REFORMCommentaries and Controversies


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