Throughout the contemporary health care reform debate there has been a good deal of consideration given to the size of the U.S. physician workforce and its impact on the health care system. Two key organiza tions — the Institute of Medicine and Pew Health Professions Commissions — have stepped into the spotlight regarding physician workforce issues.
The Institute of Medicine (IOM), chartered in 1970 by the National Academy of Sciences to enlist distinguished members in the examination of policy matters pertaining to the public health, recently published the report, “The Nation’s Physician Workforce; Options for Balancing Supply and Requirements.” The Pew Health Professions Commission, with the mission to assist workforce policy makers and educational institutions in producing health care workers who meet the changing need of the American health care system, recently released their third report entitled, “Critical Challenges: Revitalizing the health Professions for the Twenty-First Century.” As the U.S. Congress continues to evaluate the federal government’s role in shaping the nation’s health care workforce, these two organizations will continue to play a key role in the ongoing debate.
IOM Report
The IOM established a Committee to examine physician workforce issues. The IOM study attempts to discover if there is an aggregate physician surplus, the impact of such a surplus on cost, quality, and access to health care, and what can be done to deal with any surplus that exists.
While the Committee was hesitant to label the current level of physicians as a surplus, there was consensus that at the present time the nation has an abundant supply of physicians. A debate over the use of the word surplus revolved around the need to view the data in the context of the overall health care system. However, the Committee notes that there is just cause to be concerned that supply in the future will be excessive due to the increase in the number of physicians in training. The Committee also mentions concern about the increasing numbers of international medical graduates (IMGs).
Regarding the effect of an oversupply of physicians on key elements of the health care system, no beneficial effect can be seen on costs, access, or quality. It has not been shown that a surplus of physicians will improve the quality of patient care, and, in fact, a surplus may dilute quality. The Committee also commented on the possible underemployment and underutilization of future physicians and the waste of human resources. The high numbers of IMGs are thought of lower opportunities for able American young persons. However, the Committee does point out that too few physicians is more detrimental than too many. Ideally, society should strive for a balance between physician supply and societal requirements. The Committee strongly recommends some action be taken to moderate current growth in physician supply.
The majority of the IOM report is then devoted to various strategies for addressing the issue of physician supply. Five major policy recommendations were advocated by the Committee. These recommendations were recently presented to the Congress at a hearing on graduate medical education convened by the House Ways and Means Health Subcommittee.
- No new schools of allopathic or osteopathic medicine should be opened.
- Class sizes in existing schools should not be increased, and public funds should not be used to expand class size or open new schools.
- The total number of first-year residency slots should more closely mirror the current number of U.S. medical school graduates, although specific parameters are not addressed. The Committee realizes, however, the importance of implementing a new mechanism for replacement funding for IMG-depen dent hospitals that provide substantial care to the poor and disadvantaged.
- The U.S. Department of Health and Human Services should collect and make available information on physician supply, including the requirements and status of career opportunities. This information would be available to policymakers, educators, professional associations, and the public.
- The Department of Health and Human Services should provide resources for research on physician supply and requirements.
Pew Report
The view and intent of the Pew Commission Report is slightly different. The Pew report was intended as a guide for health care professionals. The report addresses survival and advancement in this changing health care environment. An assessment of the current reforms being undertaken in the health professions and specific examples of these reforms are included. However, the bulk of the report outlines a set of recommendations to serve as an early twenty-first century survival guide for America’s health care professions. The Pew Commission also presented these recommendations to the House Ways and Means Health Subcommittee.
In making its recommendations, the Commission differentiated between the actions necessary for medicine, nursing, dentistry, pharmacy, and public health.
Some general recommendations related to physician workforce and training issues. For example, the Commission recommended the development of partnerships. These alliances would be with managed care organizations for training and clinical research, with computer companies to develop information systems, and with state governments to meet the health needs of the public. Recommendations for allied health professions include improved education and practice linkages with diverse delivery environments, and the creation of innovative collaborations between professional associations. It was also noted that the collection, evaluation and dissemination of data related to allied health education and training should also be improved.
The Pew Commission recommendations for physicians include the following key provisions:
- Decrease the number of graduate medical training positions to the number of U.S. medical school graduates plus 10%.
- Reduce the size of new medical classes by 20-25% over the next ten years. This goal should be met by closing medical schools and not by reducing class size.
- Graduate medical training programs should be redirected so that by the year 2000 a minimum of 50% of all programs are in primary care areas (which includes family medicine, general internal medicine, and general pediatrics).
- Create a public/private payment pool for funding health professions educa tion. This pool would be tied to insurance premiums and would achieve public health policy goals.
The debate on graduate medical education and physician workforce will likely continue well into the future. While many believe there is an oversupply of physicians in this country, there is no agreement on how to precisely address this potential problem. In the sort term, the Congress will likely consider such remedies as restricting the number of IMGs eligible for graduate medical education funding and reduced funding for surgical residents. President Clinton has proposed the creation of an independent Commission to further
study the issue and make specific recommendations. Regard less of the approach taken, the recommendations and proposals must be based on sound and reliable research and data. The AANS and CNS will monitor and be participants in this ongoing debate.
Addenda
Medicare Practice Expenses. The Health Care Financing Administration (HCFA) is continuing its data collection and research to develop new resource-based practice expenses for the Medicare Fee Schedule. The AANS and CNS continue to have concerns about this effort, particularly the timetable for implementation. HCFA is currently one year behind schedule, but is nevertheless required by law to implement the new values on January 1, 1998. We are concerned that the agency will use proxy data and formulas to create the values. The AANS and CNS, along with over 25 other medical specialties, are lobbying Congress to amend the new law and give HCFA an additional year to conduct the research. In the meantime, to ensure that neurosurgeon’s practice expenses are adequately accounted for, the AANS and CNS are participating in the HCFA data collection process as well as a private study being conducted by the American College of Surgeons.
Medicare Fee Schedule. HCFA recently published a proposed rule for the “Five-Year Review” of the RBRVS, which will make changes to the current physician work values of the Medicare Fee Schedule. Overall, neurosurgery received a 0.2% increase in its values, and almost all of our recommendations were accepted by HCFA. All the Evaluations and Management (E/M – office visits, consults, etc.) were also increased. The proposed changes to all the relative values, however, will increase the total payments under the Medicare fee schedule. Therefore, to maintain budget neutrality, HCFA will have to apply a -7.63% budget neutrality adjustment.
Despite the increase in the E/M codes, HCFA did not increase the E/M compo nent of global surgical services. The AANS and CNS will urge the agency to make these adjustments when we submit our comments.
Medicare Conversion Factor. The current estimates for the 1997 Medicare conversion factor are as follows: $41.66 for surgical services (+2.1%), $36.41 for primary care (+2.8%), and $34.42 for other services (-0.6%).
Copies of the Institute of Medicine report are available from:
National Academy Press
2101Consitution Avenue, N.W., Box 285
Washington, DC 20055
(800) 624-6242
Copies of the Pew Commission reports are available from:
Pew Health Professions Commission
UCSF center for the Health Professions
1288 Sutter Street, Suite 805
San Francisco, CA 94109
(415) 476-8181