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THE CRISIS of PHYSICIANS SUPPLY and the MYTHS of HEALTH CARE REFORM Richard A. Cooper, M.D. Leonard Davis Institute of Health Economics University of Pennsylvania
The Crisis of Physician Supply
Physician Supply and Demand 1980-2025
Physicians per 100,000 of population .
400 Trend Model
350
300
250
200
Shortage = 200,000 physicians
Demand
Supply
AMA Masterfile Model
Had residency programs continued to expand after 1996 at ~500/year, the US would not now be facing shortages.
Physicians per 100,000 of population .
400
Continued increase in PGY-1 positions after 1996 at 500 per year
350
300
250
200
Demand
Supply
But even increasing PGY-1 residency positions by 10,000 over 10 years will not close the gap…
Physicians per 100,000 of population .
400
350
300
250
200
Demand
Supply
+1,000 per yr x10 + 500 per yr 2010-25 No change
…and the gap will continue for decades. None of us has ever experienced shortages such as these.
Physicians per 100,000 of population .
400
350
300
250
200
+1,000/yr 2010-2030
+500/yr 2010-2050
Demand
Supply
The Myths of Health Care Reform #1 Unexplained geographic variation in health care is due to the overuse of supply-sensitive specialty services. #2 If spending everywhere could be the same as in the lowest-spending regions, the US could save 30%. #3 States with more specialists have lower quality care. #4 Areas with fewer specialists and more primary care physicians have better health care at lower costs. #5 The US spends more than other developed countries but it has worse outcomes. Therefore, the US doesn’t need more physicians; it
Realities Poverty is the major factor affecting geographic variation in health care. Shortages of specialists is the major factor that will adversely affect health care quality.
A Brief Lesson about Poverty in America --- Poverty is geographic --Regional Poverty Urban Poverty Ghettos
Regional Poverty
20% Lowest 20% Highest Matthew Cooper, 2009
Urban Poverty Ghettos
20% Lowest 20% Highest Matthew Cooper, 2009
Chicago Income = 114% of US Average
Poverty, 2000 0 - 20% 20 - 40% 40 - 60% 60 - 80% 80 - 100%
The Bruton Center The University of Texas at Dallas
Philadelphia Income = 118% of US Average
The Bruton Center The University of Texas at Dallas
Dallas –Ft Worth Income = 107% of US Average
The Bruton Center The University of Texas at Dallas
New York – Newark Income – 137% of US Average
The Bruton Center The University of Texas at Dallas
Poverty and Health Care Utilization Hospital Days and Per Capita Income
Hospital Admissions Ratio Poor vs. Wealthy Regions 8
1 ,0 0 0
6 Days
750
per
6
Days per 1,000
4
1,000
4
500
2
250
0
Per Capita Income Asthma
Milwaukee ZIP Codes
COPD
CHF
2 Diabetes
Myth #1
“Unexplained geographic variation in health care is due to the overuse of supply-sensitive specialty services.” Milwaukee HRR Wisconsin
Dartmouth Atlas, 2003 (from Orszag, 2007)
Milwaukee Income = 108% of US Average
The Bruton Center The University of Texas at Dallas
Wisconsin Hospital Referral Regions (HRRs) 600
”Unexplained variation”
500 Milwaukee Hospital Days per 400 1,000
30% excess
300
200
100
Wisconsin HRRs
Wisconsin Hospital Referral Regions (HRRs) 600
500 Hospital Days per 400 1,000
Variation explained by poverty Poverty Corridor Milwaukee
Milwaukee minus “Poverty Corridor”
300
200
100
Wisconsin HRRs
Myth #1 (continued)
“Unexplained geographic variation in health care is due to the overuse of supply-sensitive specialty services.”
Los Angeles
Dartmouth Atlas, 2003 (from Orszag, 2007)
Los Angeles Average Income = 108% of US Average
The Bruton Center The University of Texas at Dallas
Los Angeles vs. Minnesota ”Unexplained Variation”
2,500 Medicare Hospital Days per 1,000
LA County
2,000
1,500 From Rosenthal, et al, UCLA
Minnesota
Los Angeles vs. Minnesota Variation Explained by Poverty
2,500 Medicare Hospital Days per 1,000
2,000
1,500 From Rosenthal, et al, UCLA
LA Poverty Core
LA County LA minus Poverty Core Minnesota
Myth #2
“If spending everywhere could be the same as in the lowest-spending quintile, the US could save 30%.”
Dartmouth Atlas, 2003 (from Orszag, 2007)
Myth #2 (continued)
“If spending everywhere could be the same as in the lowest-spending quintile, the US could save 30%.” Lowest Spending
Highest Spending
Dartmouth Atlas, 2003 (from Orszag, 2007)
Medicare Spending and
Low Spending-Low Poverty
High Spending-High Poverty
Myth #3 “States with more specialists have lower quality health care.” (Baicker and Chandra, 2004) QUALITY Best
Worst Least
SPECIALISTS per 10,000
Baicker and Chandra, Health Affairs, 2004
Most
Myth #3 It’s actually states with more SPECIALIST RESIDUALS that have and lower quality health care. QUALITY Best
Worst Least
SPECIALIST RESIDUALS
Most
Specialists and Health Care Quality Reality
22 21 20 Good
19
225
More Specialist “Residuals” Poorer Quality
Poor
Physicians/100K (Actual)
Specialist "Residuals"
23
Myth
More Real Specialists Better Quality
215 205 195 Good
185
Poor
Myth #4
“Areas with fewer specialists and more primary care physicians (i.e., family physicians) have better health care at lower costs.”
Family Practice Quartiles
High-FP
Low-FP
Low-FP
High-FP
Myth #5 “The US spends more than other developed countries, but it has worse outcomes.” 150 Mortality
Population
Spain
74
43 M
Italy
74
58 M
Canada
77
32 M
Norway
80
5M
Netherlands
82
16 M
Sweden
82
9M
Greece
84
11 M
Austria
84
8M
Germany
90
82 M
Finland
93
5M
New Zealand
96
4M
Denmark
101
5M
UK
103
60 M
Ireland
103
4M
Portugal
104
10 M
France
125
US
100 75
Preventable Mortality
50 25
OECD Countries
Deaths per 100,000 Commonwealth 2007
Australia
Mortality 65 60 M Population 71 20M
Confederacy vs. The Rest 150 125 100 75
Preventable Mortality
50 25
OECD Countries
Deaths per 100,000 Commonwealth 2007
Six Nations of White America 150 125 100 75
Preventable Mortality
50 25
OECD Countries
Deaths per 100,000 Commonwealth 2007
Six Nations of Black America 250 200 150 100 Preventable Mortality
50
OECD Countries
Deaths per 100,000 Commonwealth 2007
HEALTH CARE REFORM IS TAKING OFF
Dorothy: Come back! Come back! Don't leave without me! Come back! Wizard of Oz: I can't come back! I don't know how it works! Good-bye folks!
Payments Related to “Efficiency” An incentive payment of 5% for providers in the 20% of counties with the lowest Medicare expenditures. Payment reduced by 5% if aggregated physician resource use is above the 90th percentile nationally.
Low-poverty areas will be the winners
Payments Related to Hospital Readmissions Penalties for hospitals with more than benchmark levels of “preventable” readmissions
8 6 R atio of P oores t 4 to W ealth ies t Z on es 2 0
Hospitals that care for the poor will be the losers.
Physician Workforce Initiatives Redistribute unused residency positions. Provide financial incentives for medical graduates to choose primary care. Profound and continuing physician shortages. The sad tale of health care reform.
Conclusions The nation cannot have efficient health care if it does not address the added health care needs of the poorest members of our society. The nation will not have effective health care if it does not assure the training of sufficient numbers of physicians to provide the needed care.
Visit http://buzcooper.com
PHYSICIANS AND HEALTH CARE REFORM Commentaries and Controversies
Thank you
The Crisis of Physician Supply
Physician Supply and Demand 1980-2025
Physicians per 100,000 of population .
400 Trend Model
350
300
250
200
Shortage = 200,000 physicians
Demand
Supply
AMA Masterfile Model
Had residency programs continued to expand after 1996 at ~500/year, the US would not now be facing shortages.
Physicians per 100,000 of population .
400
Continued increase in PGY-1 positions after 1996 at 500 per year
350
300
250
200
Demand
Supply
But even increasing PGY-1 residency positions by 10,000 over 10 years will not close the gap…
Physicians per 100,000 of population .
400
350
300
250
200
Demand
Supply
+1,000 per yr x10 + 500 per yr 2010-25 No change
…and the gap will continue for decades. None of us has ever experienced shortages such as these.
Physicians per 100,000 of population .
400
350
300
250
200
+1,000/yr 2010-2030
+500/yr 2010-2050
Demand
Supply
The Myths of Health Care Reform #1 Unexplained geographic variation in health care is due to the overuse of supply-sensitive specialty services. #2 If spending everywhere could be the same as in the lowest-spending regions, the US could save 30%. #3 States with more specialists have lower quality care. #4 Areas with fewer specialists and more primary care physicians have better health care at lower costs. #5 The US spends more than other developed countries but it has worse outcomes. Therefore, the US doesn’t need more physicians; it
Realities Poverty is the major factor affecting geographic variation in health care. Shortages of specialists is the major factor that will adversely affect health care quality.
A Brief Lesson about Poverty in America --- Poverty is geographic --Regional Poverty Urban Poverty Ghettos
Regional Poverty
20% Lowest 20% Highest Matthew Cooper, 2009
Urban Poverty Ghettos
20% Lowest 20% Highest Matthew Cooper, 2009
Chicago Income = 114% of US Average
Poverty, 2000 0 - 20% 20 - 40% 40 - 60% 60 - 80% 80 - 100%
The Bruton Center The University of Texas at Dallas
Philadelphia Income = 118% of US Average
The Bruton Center The University of Texas at Dallas
Dallas –Ft Worth Income = 107% of US Average
The Bruton Center The University of Texas at Dallas
New York – Newark Income – 137% of US Average
The Bruton Center The University of Texas at Dallas
Poverty and Health Care Utilization Hospital Days and Per Capita Income
Hospital Admissions Ratio Poor vs. Wealthy Regions 8
1 ,0 0 0
6 Days
750
per
6
Days per 1,000
4
1,000
4
500
2
250
0
Per Capita Income Asthma
Milwaukee ZIP Codes
COPD
CHF
2 Diabetes
Myth #1
“Unexplained geographic variation in health care is due to the overuse of supply-sensitive specialty services.” Milwaukee HRR Wisconsin
Dartmouth Atlas, 2003 (from Orszag, 2007)
Milwaukee Income = 108% of US Average
The Bruton Center The University of Texas at Dallas
Wisconsin Hospital Referral Regions (HRRs) 600
”Unexplained variation”
500 Milwaukee Hospital Days per 400 1,000
30% excess
300
200
100
Wisconsin HRRs
Wisconsin Hospital Referral Regions (HRRs) 600
500 Hospital Days per 400 1,000
Variation explained by poverty Poverty Corridor Milwaukee
Milwaukee minus “Poverty Corridor”
300
200
100
Wisconsin HRRs
Myth #1 (continued)
“Unexplained geographic variation in health care is due to the overuse of supply-sensitive specialty services.”
Los Angeles
Dartmouth Atlas, 2003 (from Orszag, 2007)
Los Angeles Average Income = 108% of US Average
The Bruton Center The University of Texas at Dallas
Los Angeles vs. Minnesota ”Unexplained Variation”
2,500 Medicare Hospital Days per 1,000
LA County
2,000
1,500 From Rosenthal, et al, UCLA
Minnesota
Los Angeles vs. Minnesota Variation Explained by Poverty
2,500 Medicare Hospital Days per 1,000
2,000
1,500 From Rosenthal, et al, UCLA
LA Poverty Core
LA County LA minus Poverty Core Minnesota
Myth #2
“If spending everywhere could be the same as in the lowest-spending quintile, the US could save 30%.”
Dartmouth Atlas, 2003 (from Orszag, 2007)
Myth #2 (continued)
“If spending everywhere could be the same as in the lowest-spending quintile, the US could save 30%.” Lowest Spending
Highest Spending
Dartmouth Atlas, 2003 (from Orszag, 2007)
Medicare Spending and
Low Spending-Low Poverty
High Spending-High Poverty
Myth #3 “States with more specialists have lower quality health care.” (Baicker and Chandra, 2004) QUALITY Best
Worst Least
SPECIALISTS per 10,000
Baicker and Chandra, Health Affairs, 2004
Most
Myth #3 It’s actually states with more SPECIALIST RESIDUALS that have and lower quality health care. QUALITY Best
Worst Least
SPECIALIST RESIDUALS
Most
Specialists and Health Care Quality Reality
22 21 20 Good
19
225
More Specialist “Residuals” Poorer Quality
Poor
Physicians/100K (Actual)
Specialist "Residuals"
23
Myth
More Real Specialists Better Quality
215 205 195 Good
185
Poor
Myth #4
“Areas with fewer specialists and more primary care physicians (i.e., family physicians) have better health care at lower costs.”
Family Practice Quartiles
High-FP
Low-FP
Low-FP
High-FP
Myth #5 “The US spends more than other developed countries, but it has worse outcomes.” 150 Mortality
Population
Spain
74
43 M
Italy
74
58 M
Canada
77
32 M
Norway
80
5M
Netherlands
82
16 M
Sweden
82
9M
Greece
84
11 M
Austria
84
8M
Germany
90
82 M
Finland
93
5M
New Zealand
96
4M
Denmark
101
5M
UK
103
60 M
Ireland
103
4M
Portugal
104
10 M
France
125
US
100 75
Preventable Mortality
50 25
OECD Countries
Deaths per 100,000 Commonwealth 2007
Australia
Mortality 65 60 M Population 71 20M
Confederacy vs. The Rest 150 125 100 75
Preventable Mortality
50 25
OECD Countries
Deaths per 100,000 Commonwealth 2007
Six Nations of White America 150 125 100 75
Preventable Mortality
50 25
OECD Countries
Deaths per 100,000 Commonwealth 2007
Six Nations of Black America 250 200 150 100 Preventable Mortality
50
OECD Countries
Deaths per 100,000 Commonwealth 2007
HEALTH CARE REFORM IS TAKING OFF
Dorothy: Come back! Come back! Don't leave without me! Come back! Wizard of Oz: I can't come back! I don't know how it works! Good-bye folks!
Payments Related to “Efficiency” An incentive payment of 5% for providers in the 20% of counties with the lowest Medicare expenditures. Payment reduced by 5% if aggregated physician resource use is above the 90th percentile nationally.
Low-poverty areas will be the winners
Payments Related to Hospital Readmissions Penalties for hospitals with more than benchmark levels of “preventable” readmissions
8 6 R atio of P oores t 4 to W ealth ies t Z on es 2 0
Hospitals that care for the poor will be the losers.
Physician Workforce Initiatives Redistribute unused residency positions. Provide financial incentives for medical graduates to choose primary care. Profound and continuing physician shortages. The sad tale of health care reform.
Conclusions The nation cannot have efficient health care if it does not address the added health care needs of the poorest members of our society. The nation will not have effective health care if it does not assure the training of sufficient numbers of physicians to provide the needed care.
Visit http://buzcooper.com
PHYSICIANS AND HEALTH CARE REFORM Commentaries and Controversies
Thank you
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