Home

Summary of Eighth Report

Patient Care Physician Supply and Requirements:

Testing COGME Recommendations

November 1996 Executive Summary

Page 1   2   3  

Background

In its Third Report, Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century, COGME made recommendations to address the problems of physician oversupply, increasing specialization, geographic maldistribution, and minority underrepresentation. Recognizing a progressive oversupply of specialists as well as a shortage of generalist physicians, COGME set forth goals for the number and type of physicians entering residency. It was recommended that the number of physicians entering residency be reduced from 140% to 110% of the number of graduates of allopathic and osteopathic medical schools in the United States in 1993 and that the percentage of those graduates who complete training and enter practice as generalists should be increased from the current level of 30% to 50% (ie, the so-called "110:50/50 recommendation"). The Fourth Report issued by COGME provided an update of the Third Report and recommended legislation to achieve these workforce goals though allocation of reduced numbers of residency positions to consortia of medical schools and teaching hospitals. The Sixth Report, Managed Health Care, documented fundamental changes occurring in the United States health care systems and outlined implications for medical education and the physician workforce based on a reassessment of physician supply and requirements. In response to a changing congressional environment, COGME's Seventh Report, Physician Workforce Funding Recommendations for Department of Health and Human Services' Programs, recommended that planned reductions in Medicare funding of graduate medical education (GME) be targeted specifically to reducing the number of first-year residents by reducing GME payments for international medical graduates (IMGs).

The implications of implementing the 110:50/50 recommendation of COGME's Third Report are great. First-year residency positions in the United States would be reduced from 25,000 to approximately 19,600 - a 22% decrease. The number of physicians entering specialties would drop 44%, while the number of generalist physicians would increase by one-third.

Since publication of the Third Report in 1992, the health care delivery system has been changing rapidly as a result of progressive implementation of managed systems of care and competitive medical practice. Consequently, in this report physician supply and requirements are reassessed in the context of a health care system increasingly dominated by a managed care. Methodologies and available analyses for forecasting patterns of physician utilization (ie, requirements) are compared under various assumptions, and the appropriateness of the 110:50/50 recommendations for GME are reassessed. In addition, COGME's position regarding the specialty compositional the workforce and the output of training programs is clarified.

Physician Supply

In the 1960s and 1970s, in response to a physician shortage, the number of graduates of medical schools in the United States doubled and the United States government fostered immigration of physicians trained in foreign medical schools. When the shortage eased, the number was not adjusted subsequently. While the output of medical schools in the United States has remained stable for over a decade, the number of IMGs who entered residency training each year almost doubled between 1988 and 1994 - from 3,600 to 6,700. As a result, the number of first-year residency positions filled has increased to 140% of the number of United States medical graduates (USMGs), and the nation's physician-to-population ratio has increased rapidly.

Between 1965 and 1992, the patient care physician-to-population ratio (excluding resident physicians) increased by 65%, from 115 to 190 physicians per 100,000 population, almost entirely in the medical specialties. The specialist physician-to-population ratio increased by 121%, from 56 to 123 specialists per 100,000 population, while the generalist ratio increased only 13%, form 59 to 67 generalists per 100,000 population.

If numbers of those entering GME remain at current levels, the patient care physician-to-population ration will continue to increase until 2010 - an additional 15% over the 1992 level - from 190 to 219 physicians per 100,000 population. Assuming that 70% will continue to enter specialty practice, the specialist-to-population ratio will increase another 23%, from 123 to 152 specialists per 100,000, while the generalist physician-to-population ratio will remain stable at 67 per 100,000.

These projections may actually understate the future total patient care physician supply. Entry into GME in this country is a pathway to entering practice in the United States for both domestic and international medical school graduates. The increases in IMGs could continue. Several new schools of osteopathy are under development, adding to the medical supply. Furthermore, anecdotal reports suggest that the unprecedented demand by United States citizens for medical education is leading to increases in their enrollment in schools outside the United States that are not accredited by the Liaison Committee for Medical Education.

The estimates of future numbers of generalists may also be understated, inasmuch as these projections are based on past patterns of specialty choice. As perceptions of a surplus of specialists become prevalent, graduates of medical schools in the United States appear to be exhibiting increased interest in generalist specialties. According to information derived from the Association of American Medical Colleges Graduation Questionnaire, medical students' interest in generalist careers has increased from its nadir of 14.6% in 1992 to 27.6% in 1995. At the same time, students' interest in the medical subspecialties and hospital-based specialties appears to be declining.

It is unclear what long-term impact this increasing interest in generalist specialties will have on total numbers of physicians entering specialty medicine. In the past, patterns of reimbursement for GME have provided incentives for hospitals to maintain and expand their training programs. Residents provide valued service and are a source of revenue through GME reimbursement. These incentives may result in increasing numbers of IMGs being recruited to fill vacant subspecialty positions, in which case the surplus of specialists would not be moderated.

Congress now is contemplating reductions in the funding of GME. It is COGME's belief that across-the-board reductions may have little impact on the total number of residents entering GME. Targeted reductions that decrease funding in the subspecialties may result in more physicians entering generalist specialties but may not reduce total numbers entering GME. However, targeted reductions in GME reimbursement for IMGs - such as those recommended in COGME's Seventh Report - are most likely to reduce total numbers of physicians.

Page 1   2   3