The Supply and Distribution of the Preventive Medicine Physician Workforce.

CONTEXT: Preventive medicine physicians work at the intersection of clinical medicine and public health. A previous report on the state of the preventive medicine workforce in 2000 revealed an ongoing decline in preventive medicine physicians and residents, but there have been few updates since. OBJECTIVE: The purpose of this study was to describe trends in both the number of board-certified preventive medicine physicians and those physicians who self-designate preventive medicine as a primary or secondary specialty and examine the age, gender distribution, and geographic distribution of this workforce. DESIGN: Analysis of the supply of preventive medicine physicians using data derived from board certification files of the American Board of Preventive Medicine and self-designation data from the American Medical Association Masterfile. SETTING: The 50 US states and District of Columbia. PARTICIPANTS: Board-certified and self-designated preventive medicine physicians in the United States. MAIN OUTCOME MEASURES: Number, demographics, and location of preventive medicine physicians in United States. RESULTS: From 1999 to 2018, the total number of physicians board certified in preventive medicine increased from 6091 to 9270; the number of self-identified preventive medicine physicians has generally decreased since 2000, with a leveling off in the past 4 years matching the trend of preventive medicine physicians per 100 000 population; there is a recent increase in women in the specialty; the practice locations of preventive medicine physicians do not match the US population in rural or micropolitan areas; and the average age of preventive medicine physicians is increasing. CONCLUSIONS: The number of preventive medicine physicians is not likely to match population needs in the United States in the near term and beyond. Assessing the preventive medicine physician workforce in the United States is complicated by difficulties in defining the specialty and because less than half of self-designated preventive medicine physicians hold a board certification in the specialty.

Building a Value-Based Workforce in North Carolina.

Health care in the United States is likely to change more in the next 10 years than in any previous decade. However, changes in the workforce needed to support new care delivery and payment models will likely be slower and less dramatic. In this issue of the NCMJ, experts from education, practice, and policy reflect on the "state of the state" and what the future holds for multiple health professional groups. They write from a broad range of perspectives and disciplines, but all point toward the need for change-change in the way we educate, deploy, and recruit health professionals. The rapid pace of health system change in North Carolina means that the road map is being redrawn as we drive, but some general routes are evident. In this issue brief we suggest that, to make the workforce more effective, we need to broaden our definition of who is in the health workforce; focus on retooling and retraining the existing workforce; shift from training workers in acute settings to training them in community-based settings; and increase accountability in the system so that public funds spent on the health professions produce the workforce needed to meet the state's health care needs. North Carolina has arguably the best health workforce data system in the country; it has historically provided the data needed to inform policy change, but adequate and ongoing financial support for that system needs to be assured.

Medicare costs and surgeon supply in hospital service areas.

OBJECTIVE: To quantify the correlates of variations of Medicare per beneficiary costs at the hospital service area level and determine whether physician supply and the specialty of physicians has a significant relationship with cost variation. BACKGROUND: The American Medical Association Masterfile data on physician and surgeon location, characteristics and specialty; Census derived sociodemographic data from 2006 ZIP code level Claritas PopFacts database; and Medicare per beneficiary costs from the Dartmouth Atlas of Health Care project. METHODS: A correlational analysis using bivariate plots and fixed effects linear regression models controlling for hospital service area sociodemographics and the number and characteristics of the physician supply. Data were aggregated to the Dartmouth hospital service area level from ZIP code level files. RESULTS: We found that costs are strongly related to the sociodemographic character of the hospital service areas and the overall supply of physicians but a mixed correlation to the specialist supply depending on the interaction of the proportion of the physician supply who are international medical graduates. The ratio of general surgeons and surgical subspecialists to population are associated with lower costs in the models, again with difference depending on the influence of international medical graduates. There is a strong association between higher costs and the local proportion of physician supply made up of graduates of non-US or Canadian medical schools and female graduates. CONCLUSIONS: These results suggest that strategies to reduce overall costs by changing physician supply must consider more than just overall numbers.

The health care workforce: will it be ready as the boomers age? A review of how we can know (or not know) the answer.

The baby-boom generation will reach the age of eligibility for Medicare starting in 2011. This large group of Americans will require more health care, and more health care workers will be needed to meet those needs. Understanding the needs as well as the size of the workforce needed requires substantial analysis and extensive data. Two major approaches can be used to make these estimates, and the choice of both methods and assumptions can affect the outcomes of any analysis. For the United States to make workforce policy decisions with the best information, we must invest in systems and resources to generate those data and support policy-making bodies that can interpret and make recommendations consistent with the analyses.

The global health workforce shortage: role of surgeons and other providers.

The debate over the status of the physician workforce seems to be concluded. It now is clear that a shortage of physicians exists and is likely to worsen. In retrospect it seems obvious that a static annual production of physicians, coupled with a population growth of 25 million persons each decade, would result in a progressively lower physician to population ratio. Moreover, Cooper has demonstrated convincingly that the robust economy of the past 50 years correlates with demand for physician services. The aging physician workforce is an additional problem: one third of physicians are over 55 years of age, and the population over the age of 65 years is expected to double by 2030. Signs of a physician and surgeon shortage are becoming apparent. The largest organization of physicians in the world (119,000 members), the American College of Physicians, published a white paper in 2006 titled, "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care" [37]. The American College of Surgeons, the largest organization of surgeons, has published an article on access to emergency surgery [38], and the Institute of Medicine of the National Academies of Science has published a book on the future of emergency care (Fig. 10). The reports document diminished involvement and availability of emergency care by general surgeons, neurologic surgeons, orthopedists, hand surgeons, plastic surgeons, and others. The emergency room has become the primary care physician after 5 PM for much of the population. A survey done by the Commonwealth Fund revealed that less than half of primary care practices have an on-call arrangement for after-hours care. Other evidence of evolving shortage are reports of long wait times for appointments, the hospitalist movement, and others. The policies for the future should move beyond dispute over whether or not a shortage exists. The immediate need is for the United States, as a society, to commit to workforce self sufficiency in health care. The reliance on international graduates for more than 25% of the nation's physicians is a transnational problem. Reliance on IMGs, nurses and other health professions for the United States workforce is an issue of international distributive justice. Wealthy, developed countries, such as the United States, should be able to educate sufficient health professionals without relying on a less fortunate country's educated health workers. The 2000 Report of the Chair of the AAMC, the accrediting agency for United States and Canadian medical schools through the LCME, recommended expansion of medical school class sizes and expansion of medical schools [41]. For the past 25 years, the AAMC has supported a no-growth policy and the goal that 50% of USMGs be primary care physicians. In 2003, the AAMC developed a workforce center,-led by Edward Salsberg. The workforce center has provided valuable data and monitoring of the evolving workforce graduating from medical and and osteopathic schools in the United States. The NRMP, also managed by the AAMC, has begun useful studies analyzing the specialty choices of the more than 20,000 participants in the Match each year. The AAMC workforce policy was altered in 2006, and a 12-point policy statement was issued (see http://aamc.workforceposition.pdf). Three of the 12 points reflected significant change from past positions. They are a call for a 30% increase in physicians graduated by United States allopathic medical schools and an increase in residency positions now limited by the BBA of 1997. The recommendation that students make personal specialty choices reversed the prior recommendation that a majority of students enter primary care practice.

The precarious supply of physical therapists across Canada: exploring national trends in health human resources (1991 to 2005).

BACKGROUND: Health Human Resource (HHR) ratios are one measure of workforce supply, and are often expressed as a ratio in the number of health professionals to a sub-set of the population. In this study, we explore national trends in HHR among physical therapists (PTs) across Canada. METHODS: National population data were combined with provincial databases of registered physical therapists in order to estimate the HHR ratio in 2005, and to establish trends between 1991 and 2005. RESULTS: The national HHR ratio was 4.3 PTs per 10,000 population in 1991, which increased to 5.0 by 2000. In 2005, the HHR ratios varied widely across jurisdictions; however, we estimate that the national average dropped to 4.8 PTs per 10,000. Although the trend in HHR between 1991 and 2005 suggests positive growth of 11.6%, we have found negative growth of 4.0% in the latter 5-years of this study period. CONCLUSION: Demand for rehabilitation services is projected to escalate in the next decade. Identifying benchmarks or targets regarding the optimal number of PTs, along with other health professionals working within inter professional teams, is necessary to establish a stable supply of health providers to meet the emerging rehabilitation and mobility needs of an aging and increasingly complex Canadian population.

Physical therapy health human resource ratios: a comparative analysis of the United States and Canada.

BACKGROUND AND PURPOSE: Health human resource (HHR) ratios are a measure of workforce supply and are expressed as a ratio of the number of health care practitioners to a subset of the population. Health human resource ratios for physical therapists have been described for Canada but have not been fully described for the United States. In this study, HHR ratios for physical therapists across the United States were estimated in order to conduct a comparative analysis of the United States and Canada. METHODS: National US Census Bureau data were linked to jurisdictional estimates of registered physical therapists to create HHR ratios at 3 time points: 1995, 1999, and 2005. These results then were compared with the results of a similar study conducted by the same authors in Canada. RESULTS: The national HHR ratio across the United States in 1995 was 3.8 per 10,000 people; the ratio increased to 4.3 in 1999 and then to 6.2 in 2005. The aggregated results indicated that HHR ratios across the United States increased by 61.3% between 1995 and 2005. In contrast, the rate of evolution of HHR ratios in Canada was lower, with an estimated growth of 11.6% between 1991 and 2005. Although there were wide variations across jurisdictions, the data indicated that HHR ratios across the United States increased more rapidly than overall population growth in 49 of 51 jurisdictions (96.1%). In contrast, in Canada, the increase in HHR ratios surpassed population growth in only 7 of 10 jurisdictions (70.0%). DISCUSSION AND CONCLUSION: Despite their close proximity, there are differences between the United States and Canada in overall population and HHR ratio growth rates. Possible reasons for these differences and the policy implications of the findings of this study are explored in the context of forecasted growth in demand for health care and rehabilitation services.

Service-linked scholarships, loans, and loan repayment programs for nurses in the southeast.

A variety of public and private programs provide financial support for the costs of nurses' training in exchange for service commitments to work in rural, underserved, and other needy areas. Little is known about the number, size, and operations of these support-for-service programs for nurses. We identified and in this article describe such programs in eight southeastern states. Eligible programs were those that in 2004 paid for all or a portion of nurses' education costs in exchange for a period of clinical nursing service within one or more of the eight targeted states. Programs obligating nurses to a specific hospital, practice, or community or to teaching roles were excluded. Programs were identified through available compendia, online searches, and telephone contacts with program directors, nursing school administrators, and state officials. Additional data on eligible programs were gathered through telephone interviews and questionnaires mailed to program staff and from publicly available documents. Data were double coded, and qualitative and quantitative analyses were conducted. Twenty-four nursing support-for-service programs met our eligibility criteria in the eight-state region: nine scholarship programs; six loan repayment programs; five service-cancelable loan programs; two loan interest rate reduction programs; and two direct incentive programs. These programs had fiscal year 2004 budgets totaling approximately $28.8-31.8 million; collectively, they received approximately 11,700 applications from nurses, signed approximately 8,300 contracts, and had a combined field strength of approximately 4,900 nurses working to fulfill their program obligations. Individual states offered between zero and five eligible programs each. Support-for-service programs are a substantial component of federal and state nursing workforce distribution efforts in the Southeast. Future research should identify and describe these programs for other regions, measure outcomes, and offer recommendations to maximize their effectiveness in alleviating nursing shortages.

Workforce issues in rural areas: a focus on policy equity.

Rural communities in the United States are served by relatively fewer health care professionals than urban or suburban areas. I review the geographic distribution of 6 classes of health professionals and describe the multiple government and private policies and programs intended to affect their geographic distribution. These programs can be classified into 3 categories--coercive, normative, and utilitarian--that characterize the major policy levers used to influence practice location decisions. Health workforce policies must be normative to ensure equity for rural communities, but goals in this area can be achieved only through a balance of utilitarian and coercive mechanisms.