MGMA: No fix for U.S. doc shortage
LAS VEGAS—The U.S. physician workforce will continue to fall, especially for specialists like surgeons; thus, providers should begin evaluating staffing alternatives now, according to an Oct. 25 presentation at the Medical Group Management Association (MGMA) 2011 annual conference.

The problem
The number of active patient care physicians, including MDs and DOs, per 100,000 people in the U.S. population was 213 in 2009, and of that group, 37.6 percent are greater than 55 years of age, reported co-presenter Jon Mayer, MSN, MBA, department administrator in the department of surgery at Medical College of Wisconsin (MCW) in Wauwatosa. “Specialty physicians are currently the largest number of active physicians, but that number also is expected to decrease,” he added.

As oft-cited, the number of elderly will double by 2030. In fact, the number of Americans over the age of 65 years is predicted to increase 104 percent from 2000 to 2030, according to the U.S. Census Bureau. 

As a result, the demands for medical care are increasing. Due to the aging population, the U.S. Social Security Administration has reported that there were 3.3 workers per retiree in 2010, and predicted there will only be two workers per retiree in 2050. In addition, the Congressional Budget Office has estimated that under the Patient Protection and Affordable Care Act, approximately 32 million more Americans will gain health insurance. 

Based on these supply and demand statistics, the shortage of physicians in the U.S. is predicted to hit 91,500 by 2020, based on a June 2010 analysis from the Association of American Medical College’s (AAMC) Center for Workforce Studies.

Specifically, the surgeon population will be particularly hard-hit across specialties. In 2005, there were 34,000 OB/GYN surgeons, equating to 27.1 surgeons per 100,000, and even though the number of OB/GYN surgeons is expected to increase to 36,499 per 100,000 by 2030, it will only mean 19.73 per 100,000 people—translating into a 27 percent shortage (Annals of Surgery 2009;250(4):590-597). Due to the situation with aging population and the trending of disease states, the situation with thoracic surgeons could be worse, as it is predicted that there will only be 0.87 thoracic surgeons per 100,000 people by 2030—a 39 percent shortage.

On top of the shortage, physicians are seeking to work fewer hours for better work/life balance, Mayer said. 

Also compounding the problem is the limitation to the hours that residents can work in the hospital by the Accreditation Council for Graduate Medical Education (ACGME). In year one after graduation, residents’ duty hours must be limited to 80 hours per week, averaged over a four week period, and they must be scheduled for a minimum of one day free of duty every week. Only residents four and five years after graduation may have instances when they can stay over their duty time (within 80 hours) to provide care to a patient or gain a unique experience.

Seeking alternatives
There are few options, according to Mayer, to address a decreasing supply of physicians yet increasing demands of patients:
  • Keep the population healthy through preventive care, so not as much care is needed;
  • Expand provider alternative staffing models; and
  • Improve efficiency (i.e. throughput). 
To bolster the lack of physicians, there are a few staffing options, including hospitalists; unaccredited (non-ACGME) fellows; and medicine specialists supporting surgical specialties.

Co-presenter Michelle Behling, MBA, department administrator for the departments of anesthesiology and orthopedic surgery at MCW, said it is particularly beneficial to utilize physician assistants (PAs) and nurse practitioners (NPs) to replace certain roles of physicians. 

There are 140 accredited PA programs in the U.S., and the number of positions will increase by 27 percent between 2006 and 2016, according to the U.S. Bureau Labor Statistics. Likewise, there are 92 Doctorate of Nursing Practice programs in the U.S. with 1,807 students enrolled and 122 graduates as of the fall 2007. An estimated 147,295 NPs are practicing (two-thirds in adult or family care), with 10,000 running their own practices in 11 states.

MCW, which employs 1,250 physicians and is affiliated with two hospitals—one adult and one pediatric, has seen an increase in PAs and advanced practice nurses (APNs). In 1997, there were 41 PAs/APNs, and in 2011, there were 298 in 2011—a 152 percent growth. 

To proactively encourage more involvement, MCW polled its PAs and APNs to assess their job satisfaction and concerns. Then, they established councils for practice (to articulate and clarify scope of practice and integrate the full scope of the roles into the practice settings); resource (communication, billing metrics, compliance and criteria for performance appraisals); and education (credentialing, continuing education, preceptorship and mentorship).

MCW also developed a post-graduate surgical PA training program, which includes structured didactic learning and supervised clinical training, and resulted in significant surgical exposure and shortened learning curve. The provider also is developing an acute care NP fellowship.

Other provider alternatives are surgical assists and genetic counselors. 

Mayer concluded that it is tremendously important to balance resident and fellow learning needs with patient service needs.