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Summary of Third Report

Chapter 1 - Introduction: The Crises in Health Care Delivery and Physician Workforce Supply

In 1988, when COGME issued its first report to the Secretary and Congress, it expressed concern that physician specialty and geographic maldistribution was growing despite an increasing aggregate supply of physicians. At that time, concerns about access to health care and rising health care costs had not yet been so prominently thrust into the national spotlight. Similarly physician workforce policy was not high on the national agenda.

The historical context of this report is vastly different. Today the health care system is acknowledged to be in crises. While health care expenditures exceeded $650 billion in 1990 and are projected to reach $1 trillion in 1995, 37 million Americans remain medically uninsured, and millions more face barriers to basic health care. Furthermore, the Nation's basic health status indicators, which are in some measure influenced by access to health care, lag behind most economically developed countries. There is now recognition that health care reform to ensure access to basic care for all Americans is not possible without physician workforce reform. It is in this context that COGME has been examining physician workforce supply and distribution and its impact on ensuring access to care for all Americans.

The Crisis in Health Care Delivery

Within the community of nations, The United States leads in biomedical research, technology development, and some aspects of health care delivery. The United States produces excellent physicians and leads in the development, application, and diffusion of new technologies for disease diagnosis and treatment. The United States also is recognized for innovations in health care delivery systems such as HMOs and other managed care systems.

Nevertheless, the health care system has notable flaws. Although the United States spends far more per capita on health care than any other nation, millions of Americans face significant barriers trying to obtain basic health services. The United States pioneers in biomedical research and sophisticated medical technology funded through the National Institutes of Health (NIH), but basic health status indicators lag far behind other developed countries. Although the Centers for Disease Control has led advances in epidemiology and disease prevention and control, the actual performance of the health care system in providing basic screening, counseling, and immunization services is considered to be far below target levels.

Today, public concern about the health care crises is expressed through the sheer number of national health care reform proposals that have been introduced. The major elements of the health care crisis include:

• Inadequate access to care.
• Poor and/or unequal health status within the population.
• The high cost of health care.

Inadequate Access to Health Care

The problems associated with access to health care have deeply rooted social, economic, and educational implications. Significant numbers of people do not have access to affordable and quality health care, and the numbers continue to increase, Availability of insurance or other third-party coverage is a necessary means of access for preventive and medical services. Yet 37 million Americans lack health insurance, three-fourths of them are fulltime workers and their families, and another 16 million have inadequate coverage. In 1990, 17 percent of the nonelderly U. S. population did not have private or public coverage. In 1988, two-thirds of the uninsured population were in families of full-year steadily employed workers. These individuals and their families face barriers in obtaining medical care and are less likely to get preventive care or adequate care when faced with serious illness.

Studies have shown that lack of insurance coverage is the major barrier to health care. Without insurance coverage, many individuals and their families forgo medical care or opt for reduced care. One recent study showed data indicating that lack of access to basic care in Washington, D.C., and the United States resulted in excess needless premature deaths among African Americans from common treatable conditions such as asthma, pneumonia, hypertension, and tuberculosis. Similarly, studies in New York City indicate that residents in low-income census tracts were significantly more likely to be hospitalized for common conditions that can be treated with access to basic health care.

Poor and/or Unequal Health Status Within the Population

Many socioeconomic factors affect health status, including poverty, unemployment, lack of education, poor housing, and unsafe neighborhoods. Figure 1 displays indicators of health status and medical care utilization by race and poverty status. This information provides evidence that the health status of individuals in the population varies according to race and socioeconomic status. Simply stated, our Nation's most vulnerable citizens - minorities, the poor, the unemployed, and the poorly educated - are at greatest risk for poor health.

However, health problems are exacerbated by barriers to regular primary and preventive care. Unfortunately, our Nation's most vulnerable citizens are also the mostly likely to be uninsured. Although Medicaid is often considered to be the catchall program for the poor, in reality, this is not the case. At the time it was enacted as Title XIX of the Social Security Act in 1965, Medicaid was not intended to pay for medical services of all poor Americans. Instead it was designed to provide medical assistance to those in the welfare program categories of the aged, blind and disabled, and poor women or families with children thus leaving out poverty-stricken single people and childless couples. The restricted financial criteria for Medicaid eligibility have excluded the employed poor. For reasons that include these limitations on eligibility, about 60 percent of the poor do not receive Medicaid benefits. This leaves a significant gap between the number of people living below the poverty level and the actual number of Medicaid recipients. Consequently, substantial numbers of individuals do not benefit from any health program coverage for major portions of the year. The resulting lack of health care is associated with worse health status among the poor.

International comparisons also provide much ammunition for critics of the U. S. health care system. The United States fares poorly as compared with other developed countries in several major health indices:

• In 1988, the United States ranked 23rd out of 40 selected countries in terms of infant mortality (see figure 2 for U.S. comparison of infant mortality among five selected countries belonging to the Organization for Economic Cooperation and Development [OECD]).
• The United States ranks in the bottom half among the OECD countries in terms of male and female life expectancy at birth. (Figure 3)

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The High Cost of Health Care

Policymakers agree that strategies to expand access and control costs must proceed together. To pursue one goal without the other is to further undermine a system already under serious stress. The persistent and substantial increases in the costs of health care continue to alarm economists, elected officials, business, labor, and the public. Expenditures in the health care system are growing at a rate estimated to exceed $1 trillion in 1995 and $1.8 trillion in the year 2000. In every year from 1950 to 1985 except three (1973, 1978, 1984), the inflation in national spending for health care outpaced the rest of the economy. Put differently, in 1950 the United States spent about $1 billion per month in health care; by 1985 it was spending more the $1 billion per day.

When compared with other industrialized nations, the United States spends significantly more of its gross domestic product (GDP) for health care. Furthermore, health care costs continue to escalate to the detriment and sacrifice of other national goals. The per capita spending for the United States is 40 percent higher than Canada, 90 percent higher that Germany, and 127 percent higher than Japan (figure 4). Perhaps even more troubling is the continued increase in percentage of GDP in the United States through 1989, when the percentages for other industrialized countries appear to have stabilized since the early 1980's (figure 5).

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A comparative analysis of the health care costs in selected countries reveal key features that distinguish the United States from other nations in providing health care services. Compared with other countries, many more physicians in the United States choose to practice in highly focused medical specialties and subspecialties. Studies suggest that the cost of physician services is much greater in the United States and that patients undergo more intense medical services per visit because of the exceptionally high proportion of non primary care specialists in this country. Considering the staggering health care costs that continue to escalate, it is no wonder why health care issues command frontline national attention. Despite all the billions spent on health care and the remarkable increase in expenditures for biomedical research, new technology, and medical care, the United States has a rather dismal health status scorecard due to its failure to provide routine, ongoing primary care to surprisingly large segments of its population.

The Crisis in Physician Workforce Supply

Physician and health professional workforce considerations are fundamental to any discussion of health care reform strategies. The ability to provide essential health care services to all Americans depends upon the proper supply, racial/ethnic composition, specialty mix, and geographic distribution of physicians and other health professionals. If a system of insurance was provided tomorrow for all Americans to ensure access to essential health care at a reasonable societal cost, would the right mix of physicians be available to provide quality and cost-effective care? Furthermore, is our medical education system producing the right mix and supply of physicians to meet our Nation's health care needs in the 21st century? Clearly, efforts to solve the trio of inadequate access to care, skyrocketing costs and poor relative health status would be significantly hindered if America is also facing a crisis in physician workforce supply.

It is in this context that COGME has been examining physician workforce supply and distribution and its impact on ensuring access to care for all Americans. Over the past two years, the Council has focused on the following seven major questions:

1. Do we have an adequate mix of generalists and specialists to provide the most efficient and the most cost-effective system of quality care for all Americans?
2. What implications do problems of access have for recommendations on physician workforce supply, and distribution?
3. What is the status of minority representation in medicine and what effect does it have on minority health as well as the health of the public in general?
4. What are the supply needs of specific medical specialties?
5. Do we currently have adequate numbers of total physicians? Will the projected supply of physicians be adequate?
6. Can our medical education system be more responsive to the health care needs of the Nation?
7. What are the factors that have hindered efforts to attain the appropriate composition, specialty mix, and geographic distribution of physicians to ensure access to care for all Americans?

Over a two-year period since its last report, the Council received a broad range of input. This included solicited papers covering supply and demand for physicians, barriers to access to physician services, and updated need-based requirements for selected specialties. The Council limited its review of workforce assessments to the following specialties: general/family practice, general internal medicine general pediatrics, general surgery, obstetrics/gynecology, adult and child psychiatry, preventive medicine, and geriatrics.

The Council received significant testimony at plenary sessions and before its three subcommittees on Physician Manpower, Medical Education Programs and Financing, and Minority Representation in Medicine. Representatives from major organizations and policy-making bodies, including the major allopathic and osteopathic hospital and medical education organizations and major specialty organizations, have testifies on aspects leading to this third report. Major foundations have provided testimony, including the Josiah Mach, Jr. Foundation the Robert Wood Johnson Foundation, the Pew Charitable Trusts, and the Kellogg Foundation. Representatives of State and local interests, such as the New York State council on Graduate Medical Education and the National conference of State Legislatures, also testified. In addition, COGME reviewed the latest recommendations from medical educators and policy makers on medical education reform policy.

This third report to Congress and the Secretary provides the council's principles and subsequent findings, goals, and recommendations to address these major physician workforce issues of today. Chapter II contains the Council's first six major findings and goals. Chapter III contains the Council's seventh major finding and goal, which describes the major barriers to policy change that must be addressed to attain the goals and new directions. Chapter IV describes the Council's recommendations for the Nation as well as specific recommendations for out Nation's medical educators. The appendix contains projections of the total physician supply and specialty mix if COGME's recommendations were adopted.

Chapter II - Findings of COGME

Finding No. 1:

The Nation has too few generalists and too may specialists.

• The growing shortage of practicing generalists (i.e., family physicians, general internists, and general pediatricians) will be greatly aggravated by the growing percentage of medical school graduates who plan to subspecialize. The expansion of managed care and provision of universal access to care will only further increase the demand for generalist physicians.
• A rational health care system must be based upon an infrastructure consisting of a majority of generalist physicians trained to provide quality primary care and an appropriate mix of other specialists to meet health care needs. Today, other specialists and subspecialists provide a significant amount of primary care. However, physicians who are trained, practice, and receive continuing education in the generalist disciplines provide more comprehensive and cost-effective care than nonprimary care specialists and subspecialists.

Finding No. 2:

Problems of access to medical care persist in rural and inner-city areas despite large increases in the number of physicians nationally.

• Access to primary care services is especially difficult in rural and inner-city areas. Many factors contribute to the problems of access, including economic and social circumstances of rural and inner-city areas as well as the shortage of minority and generalist physicians. Minority physicians and physicians in the three primary care specialties (family practice, general internal medicine, and general pediatrics) are more likely to serve inner-city populations.
• Family physicians and general surgeons are more likely than other specialties to serve rural populations. The decline in numbers of general surgeons entering rural practice is little recognized and has significant implications for access to trauma, obstetrical and orthopedic services in rural settings and to the fiscal viability or rural hospitals.
• Consequently, more minority and generalist physicians must be educated and educational programs should specifically address skills needed in these settings. This must be accompanied by sufficient incentives to enter and remain in inner-city and rural practice and by the development of adequate health care systems in which they can practice.
• Access to one important component of primary medical care, obstetrical services, has been in the national spotlight. Problems are greatest in rural and inner-city areas. Causes include economic and sociocultural factors and the availability of obstetricians, family physicians, and nurse midwives. While the total number of obstetricians continues to increase the proportion providing obstetrical services decreases dramatically with the number of years in practice. Less that 10 percent of obstetricians practice in rural settings. Consequently, family physicians historically provide the majority of rural obstetrical care. In recent years, however, the proportion of family physicians providing obstetrical services has also declined markedly. While rising malpractice claims clearly have contributed to the decreasing provisions of obstetrical care, other factors, such as unpredictable hours, also seem to have contributed to these decisions.

Finding No. 3:

The racial/ethnic composition of the Nation's physicians does not reflect the general population and contributes to access problems for underrepresented minorities.

• Although African Americans, Hispanic Americans, and Native Americans compose 22 percent of the total population and will constitute almost one-fourth of all Americans by the year 2000, they represent only 10 percent of practicing physicians, and 3 percent of medical faculty.
• Increasing the percentage of underrepresented minorities in the medical profession is vital as a means of improving access to care and health status of these vulnerable and underserved populations. Minority physicians tend to practice more in minority/underserved areas, reduce language and cultural barriers to care, and provide much needed community leadership.
• Strategies to increase minority enrollment must emphasize increasing and strengthening the applicant pool, the acceptance rate from within this pool, and the student retention rate. These strategies must take into account disproportionately high rates of poverty, poor health status, poor schools, and a continued lack of access to educational and career opportunities. They must include both traditional short-term efforts and long-term strategies targeting younger students early in the education pipeline.

Finding No. 4:

Shortages exist in the specialties of general surgery, adult and child psychiatry, and preventive medicine and among generalist physicians with additional geriatrics training.

General Surgery

• The future growth in general surgical services is likely to exceed the growth in the supply of general surgeons. Aging of the U.S. population will increase demand for surgical services and the number of physicians in general surgery is inadequate to meet a growing need for trauma care services and for surgical care in rural areas. The training curricula for general surgery need to be broad-based to ensure that graduates have sufficient knowledge and skills to manage the wide array of surgical problems that may be seen in rural and inner-city areas.

Finding No. 5:

Within the framework of the present health care system, the current physician-to-population ratio in the Nation is adequate. Further increases in this ratio will do little to enhance the health of the public or to address the Nation's problems of access to health care. Continued increases in this ratio will, in fact, hinder efforts to contain costs.

• Efforts to solve problems of access to health care by increasing the total physician supply have been largely unsuccessful. A growing physician oversupply is projected, which will hinder efforts to contain costs. Consequently the number of physicians educated should be reduced. Strategies to improve access to care should, instead, focus on altering the specialty mix, racial/ethnic composition, and geographic distribution of physicians.

Finding No. 6:

The Nation's medical education system can be more responsive to public needs for more generalists, underrepresented minority physicians, and physicians for medically underserved rural and inner-city areas.

• The Nation's system of undergraduate and graduate medical education, taking place in 141 osteopathic and allopathic medical schools and in more than 1,500 institutions and agencies, has responded effectively to many of the Nation's health care needs. During the past 25 years, our Nation's medical education system has responded to public demands to increase the numbers of physicians, advance biomedical research, and develop new medical technology. These responses have resulted in a doubling of the physician supply and the establishment of a biomedical research and medical technology infrastructure that is unsurpassed.
• Today, the medical education system must respond to the Nation's health care and physician workforce needs in the 21st century. These include the need for more primary care research, and increased access to primary care, particularly in underserved rural and urban communities. Changes in the institutional mission, goals, admissions policies, curriculum, faculty composition and reward system, and the site for medical education and teaching are necessary to respond to these needs.

Finding No. 7:

The absence of a national physician workforce plan combined with financial and other disincentives are barriers to improved access to care.

• There is no national physician workforce plan for the United States to meet the current and projected future health care needs of the American people. In addition, there is no coordinated financing strategy and integrated medical education system to implement such a plan. Instead, such critical policy issues as the aggregate physician supply and specialty mix are the result of a series of individual decisions make by the 126 allopathic and 15 osteopathic medical schools and nearly 1,500 institutions and agencies that currently sponsor or affiliate with GME training programs. The medical education financing and health care reimbursement systems create significant disincentives to students who wish to become generalists, physicians who wish practice in underserved areas, and to the provision of basic primary and preventive services to all Americans.