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[D]

Neither reducing the number of first-year residents nor increasing the generalist output to as high as 60% would alone bring both generalist and specialist supplies within the requirement ranges of a managed care-dominated system by the year 2010. If the number of first-year residency positions is not reduced and the proportion of generalist trainees grows to 50% with the increasing attractiveness of generalist careers and reduction in GME funding of subspecialty training, the number of generalists will exceed 80/100,000 before 2010 and the ratio of specialists will markedly exceed the requirement range. However, a reduction of first-year residents to the number of USMGs plus 10%, in combination with an increase in the proportion of generalists to at least 50% of those educated annually, will minimize the projected specialty surplus while maintaining generalist supply. Under this scenario, in 2010, the specialist physician-to-population ratio will be 134 per 100,000 - 87,000 specialist physicians above the requirement range. At the same time, the generalist physician-to-population ratio will be 77 per 100,000 - 8,000 generalist physicians below the upper level of the requirement range.

[D]

[D]

The ultimate requirements for generalists and specialists will obviously depend on the configuration of future health care systems. In a competitive environment, that system will be structured through an interaction of factors including cost efficiency mechanisms, consumer desires, and workforce availability. The Council anticipates that nurse practitioners and physician assistants will be utilized increasingly, both in specialty care and in primary care. It also believes that specialists will provide a portion of primary care services for chronically ill patients in managed care systems. At the same time, COGME anticipates that generalists will assume increased roles in coordinating care and providing primary care as managed systems of care proliferate, thus reducing demand for specialists.

It has been suggested that the current generalist supply will be adequate in a system dominated by managed care. Evidence to support this conclusion is drawn from data demonstrating that generalist-to-population ratios in the United States already approximate current generalist staffing levels in many health maintenance organization (HMOs). However, these conclusions, as well as the studies utilized in establishing COGME's estimations of requirements, are derived by projecting physician staffing patterns in local systems of managed care to the nation as a whole. They do not consider the inevitable geographic variation in physician supply. While variation in physician supply across states and regions may be reduced as managed care progressively dominates the health care delivery system, it is not realistic to expect that physicians in the future will be distributed evenly. The ranges of requirements are intended to be broad enough to take into consideration geographic and other local variations.

Current levels of generalist supply have been achieved through public support of generalist training. If generalist training is to be expanded by one-third, as would be the case with implementation of the 110:50/50 recommendation, the educational infrastructure must be maintained and enhanced. Training programs, particularly those serving rural and inner-city areas, should continue to receive training grant support at least for a decade or until managed care efforts have clearly replaced these needs.

In the final analysis, COGME recognizes that the nation's most significant workforce problem is an increasing surplus of physicians, primarily of specialists. In a setting of overall surplus, the issue of optimal requirement ranges becomes moot. The real issue becomes identifying where the system has the capacity to productively employ additional physicians. At present, this country has very limited capacity to absorb additional specialists while still being able to employ many additional generalists productively.

The health care system is in a state of dynamic change. Patterns of delivery may change with time, and current data are incomplete. Ongoing studies of workforce supply and requirements are needed.

Conclusions

Despite the aforementioned uncertainties, current data support a goal that total first-year residency positions be reduced to 110% of 1993 USMGs and that 50% of this reduced number enter practice as generalists. Implementing this recommendation will require fundamental changes in current patterns of GME which should be instituted as rapidly as possible. If this goal is achieved, the nation's physician workforce will more closely correspond to physician requirements early in the next century.

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