Projection of Physician Supply and Demand in Wisconsin through … · Projection of Physician...

Projection of Physician Supply andDemand in Wisconsin through 2025

Nancy SugdenDirector, Wisconsin AHEC ProgramAssistant Dean, Academic Affairs

University of Wisconsin School of Medicine and Public Health

Presented 4-27-15Updated 6-12-15

2

Framework for analysis: Wisconsin Health Service Areas

3

• Each service area consists of ahub city and surroundingmunicipalities.

• Each service area has apopulation of at least 10,000(with a few exceptions innorthern Wisconsin and bordercommunities)

• Most service areas include ahospital, but

• Inclusion of a municipality in aservice area is determined bytravel time to the hub, not actualhospital or clinic utilization data.

For details on Wisconsin Health Service Areas, see www.ahec.wisc.edu/workforce

4

Wisconsin Health Service AreasRegions Urban & Rural Types

5

Wisconsin Health Service AreasDistribution of Primary CarePhysicians

Population to Provider Ratio

6

Wisconsin Health Service AreasProjected Retirement(% reaching age 65)

Current Population to PCPand Retirement

7

Putting it together - service areas atmost risk of shortage

8

Retirement rates - by service areatype

9

Projecting future physician supply more complicatedthan looking at retirement rates vs. medical schoolgraduates, of course.

And determining how many physicians will be neededin changing health care delivery environment evenmore challenging.

Studies and on-line tools that include projectionsmodeling a variety of scenarios are becomingavailable . . .

10

AAMC Report, March 2015Complexities of Physician Supply and Demand:

Projections from 2013 to 2025

Associa'on of AmericanMedical Colleges (AAMC)contract with IHS, Inc. toconduct the study.

Principal consultant was TimDall, who also worked onAAMC workforce projec'ons in2008 and 2010.

11

AAMC Key FindingsComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

• Demand for physicians con1nues to grow faster than supply, leading to aprojected shor9all of between 46,100 and 90,400 physicians by 2025.

• Although physician supply is projected to increase modestly between 2013and 2025, demand will grow more steeply.

• Across scenarios modeled, total physician demand is projected to grow by86,700 to 133,200 (11-‐17%), with popula'on growth and aging accoun'ng for112,100 (14%) in growth.

• By comparison, physician supply will likely increase by 66,700 (9%) if laborforce par'cipa'on paTerns remain unchanged, with a range of 33,700 to94,600 (4-‐12%), reflec'ng uncertainty regarding future re'rement and hoursworked paTerns.

• Expanded medical coverage achieved under ACA once fully implemented willlikely increase demand by about 16,000 to 17,000 physicians (2.0%) over theincreased demand resul'ng from changing demographics.

12

AAMC Key Findings (continued)Complexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

• Projected shorYalls in primary care will range between 12,500 and 31,100physicians by 2025, while demand for non-‐primary care physicians will exceedsupply by 28,200 to 63,700 physicians.

• The projected shorYall is especially acute for surgical special'es (excludingobstetrics and gynecology where demand is projected to grow slowly).

• The lower ranges of the projected shorYalls reflect the rapid growth in supplyof advanced prac'ce nurses, with the rapid growth in supply of PAs alsohelping to mi'gate the shorYall. However, even in the scenarios where theseclinicians play an increased role in pa'ent care delivery, physician shortagesare projected to persist.

• Due to new data and the dynamic nature of projected assump'ons, theprojected shorYalls of physicians in 2025 are smaller than shorYalls projectedin the earlier study.

13

AAMC ConclusionsComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

“The projected range for the shortage reflects uncertain'es regarding howemerging care delivery models might change health care use and deliverypaTerns, as well as uncertain'es regarding physician labor force par'cipa'onpaTerns (i.e., re'rement and work-‐life balance decisions). Together, thisuncertainty combined with con'nued research and updated data on supplyand demand determinants underscores the importance of con'nuallymonitoring the state of the physician workforce to ensure access to highquality and affordable care.”

14

Physician Supply Projectionsfor 2025

AAMC supply scenarios&

application to Wisconsin

15

Current Workforce - base supply used forprojections

• AAMC Study -‐ AMA Physician Masterfile 2013 data for physiciansunder 75

• Wisconsin– Wisconsin physician licensure data 3-‐15-‐12, obtained for all physicians at

conclusion of 2011-‐12 re-‐licensure

– Our recent work on physician distribu'on and re'rement based onphysicians < age 65. Used that as base for our projec'on, resul'ng in aprojec'on for # of physicians <65 rather than <75 as in the AAMC study.

• If we used physicians <75, the base count would be 14,179, or 9.8% higher,about the same as the % of physicians 65-‐75 in the AMA Masterfile data usedby the AAMC.

Need to keep this difference in the base supply in mind when comparingpopula'on to physician ra'os.

16

12,802

14,173

767,200

Total

10%4055(29%)

2783(20%)

1912(13%)

5423(38%)

WI<age 75

3645(28%)

245,500(32%)

OtherSpecialties

1688(13%)

125,600(16%)

Medical Sub-specialties

2411(19%)

155,300(20%)

SurgicalSpecialties

0

10%

% Age65-75

5058(40%)

WI<age 65

PrimaryCare

240,800(32%)

National< age 75

Compare AAMC Report (AMA Masterfile2013) to Wisconsin data

17

• Our es'mate of current Wisconsin shortage higher thanes'mate AAMC used for na'on as a whole, par'cularly inpsychiatry.

• Both es'mates based on # needed in 2013 to removefederal HPSA designa'ons.

PsychiatryPrimary Care

200 (22%)200 (3.6%)WI

2800(~7.0%)8200 (3.3%)Na'onal

Current shortages

Percent short of demand based on current # physicians < 75 pluscurrent shortage.

18

Physician Supply:Needed to meet current demand (2012/2013)

5,686,986316,500,000Population

256.2 per 100,000245.9 per 100,000Physicians per100,000 after fillingshortages=current demand

14,573778,200# needed to meetcurrent demand

40011,000# short

14,173767,200Current supply

Wisconsin 2

(physicians < age 75)U.S.1

(physicians < age 75)

1 U.S. baseline data and national projections throughout this presentation are from theComplexities of Physician Supply and Demand, AAMC, March 20152 Wisconsin baseline data is from Wisconsin Physician Workforce Report, October 2012.

19

Current (2012) physician supply and demand inWisconsin, by specialty group -

physicians under age 75

412:11520:18485:12038:12520:11314:1National ratio

11,00028008200Shortage (HPSAs)

~208,200

3360

1692:1

3360

Other

767,200~37,300155,300125,600240,800National

401:18183:12043:12974:11049:1Current ratio

14,573895278319125623# needed to meetcurrent demand

400200200# short**

14,173695278319125423Current supply

AllPsychiatrySurgicalSpecialties

MedicalSubspecialties

PrimaryCare

*WI Population 5,686,986 based on 2010 U.S. Census. U.S. population 316.5 million in 2013.**Shortage estimate based on number needed to remove areas currently designated as HPSAs.

20

Physician Supply ScenariosComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

• Status quo supply projec'on to 2025 (paTerns of re'rement andhours of work same as at present, projec'on based on current GMEpipeline)

8.7% increase overall

10.8% primary care

13.4% medical special'es

(0.13%) surgical special'es

9.8% other special'es

• Our projec'on for 2025 will apply these % increases by specialty tobaseline Wisconsin data

21

Physician Supply:Projected for 2025 based on current or planned medical school

enrollment and GME slots, and if no change in current hours of workand re'rement

402:1

6,203,850

15,405

1232

14,173

WisconsinPhysicians <75

13,928833,900Projected supply, status quo

12,802767,200Current supply

112666,700increase

6,203,850347,300,000Projected population 2025

445:1416:1Population to physician

WisconsinPhysicians <65

U.S.Physicians <75

• AAMC % increase by specialty group applied to Wisconsin mix of physician special'es.

• Projec'on assumes that Wisconsin is able to recruit its share of the na'onal supply of new physicians.

22

Application to Wisconsin:Modeling physician supply

• Our base supply begins 2012; AAMC study begins at end of 2012.

• AAMC study uses ac've physicians <75 in the AMA Masterfile fortheir base supply (and supply projec'ons are for physicians < age 75).They note that physicians age 65-‐75 make up 10% of their base group.

• Our previous work has used physicians <65 as a best es'mate ofphysician FTE. If we used physicians <75, the base count would be14,173, or 9.8% higher,but we wouldn’t be able to do more localizedprojec'ons that rely on physician loca'on (such as regions withinWisconsin, or health service areas by type).

• Physician prac'ce loca'on is more likely to match the address in theWI licensure record (our source of physician data) for physicians < 65.

• We apply the AAMC % increase to physicians under age 65 in 2012and end with a projec'on for physicians < age 65 in 2025.

23

Application to Wisconsin:Modeling physician supply (continued)

• Wisconsin results will vary from na'onal resultsto the extent that our ini'al shortage and thephysician specialty mix is different.

• This will be apparent in the projec'ons for serviceareas by type, where primary care physiciansmake up most of the rural service area workforce.

• It will be less apparent in projec'ons for serviceareas by region, as most regions include a majormedical center and full range of special'es.

24

Wisconsin Physicians < Age 65 by Service Area Type andSpecialty

23.9%

20.4%

12.0%

18.3%

23.3%

16.2%

24.5%

27.8%

% Other

3.4%13.8%1.1%69.7%617RuralHub > 2500

3.1%13.1%4.6%58.8%260RuralHub < 2500

4.5%18.8%13.2%39.5%12,802All

2.3%18.3%4.8%56.3%311MixedHub > 10,000

3.3%18.3%12.4%42.7%630MixedHub < 10,000

4.3%22.8%9.1%47.5%714Urban

4.1%19.0%14.2%38.1%7241Metro

6.4%19.1%15.9%30.8%3029Metro-Academic

% Psychiatry% SurgicalSpecialties

% MedicalSubspecialties

% PrimaryCare

Number ofPhysicians< age 65

25

Wisconsin Physicians < Age 65 by Region and Specialty

24.9%3.0%19.6%11.5%41.1%1006Wausau

23.9%

27.5%

6.6%

11.1%

19.9%

19.3%

8.6%

17.8%

23.6%

18.9%

28.0%

28.3%

19.7%

18.7%

23.9%

16.6%

21.5%

% Other

4.2%17.8%11.6%47.1%696La Crosse

3.0%20.4%11.3%45.4%690Eau Claire

3.1%13.6%1.2%71.0%162West Central

3.3%18.0%3.3%68.9%61Superior

3.1%18.7%5.7%45.1%193Rhinelander

4.5%18.8%13.2%39.5%12,802ALL

4.6%16.5%15.5%35.1%4028Milwaukee

4.8%21.0%9.5%36.7%651Waukesha

4.6%21.3%12.3%42.9%545Southeast WI

6.5%17.6%15.0%37.2%2183Madison

4.3%23.2%12.1%42.6%371Janesville

5.7%17.1%0.0%68.6%35Southwest WI

3.9%23.6%6.4%46.4%233Fond du Lac

6.7%16.9%9.3%48.4%225Oshkosh

3.5%21.6%11.9%39.1%624Appleton

5.2%21.8%18.6%37.8%307Sheboygan

3.3%24.2%13.0%38.0%792Green Bay

% Psychiatry% SurgicalSpecialties

% MedicalSubspecialties

% PrimaryCare

Number ofPhysicians <

age 65

26

Application to Wisconsin:Modeling physician supply (continued)

• The AAMC report uses Florida physician workforcesurveys for hours worked and aTri'on in order toes'mate overall FTE by specialty. How might Wisconsinphysicians be different? Hours of work informa'on fromour physician survey could be compared to the Floridadata.

• The AAMC report projects an increase in supply under the“status quo” scenario of 8.7% by 2025. This is based onmedical school enrollment increases already implementedor planned, and current GME training slots.

27

Application to WisconsinModeling physician supply (continued)

Wisconsin’s experience:

• 9.9% increase in WI medical schools enrollment 2002-‐2012(AAMC databook)

• 24.4% increase in WI GME 2001-‐2011 (AAMC databook)

28

Wisconsin Physician Supply:Status quo projection for 2025, by discipline

Physicians under age 65

13,202306782241116885258# needed to meetcurrent demand

9709:1

639

57

assumesame as

Other

200

9771:1

582

Psychiatry

400200# short**

1126301(3)227544Increase

444:11857:12359:13369:11124:1Current ratio

8.7%9.8%(incl. Psych)

(.13%)13.5%10.8%Projected increaseover current supply(from AAMC study)

445:11844:12576:13239:11107:1Population tophysician 2025

13,9283364240819155602Projected supply,status quo supplyscenario

12,8023063241116885058Current supply

AllOtherSurgicalSpecialties


PrimaryCare

*2025 WI population projection: 6,203,850 based on 2013 WI DOA projection.Shortage estimate based on number needed to remove areas currently designated as HPSAs.Wisconsin baseline data is for physicians under age 65.

29

Alternate physician supply scenarios modeledin the AAMC study

• Older physicians re're 2 years earlier than the currentpaTern by specialty

• Older physicians delay re'rement un'l 2 years later thanthe current paTern

• Millennials con'nue their current preference for shorterhours into their 40’s and 50’s

• Modest GME expansion (a policy scenario)

30

Physician Supply:alternate scenarios in AAMC study

5.5%6.3%(3.0%)10.0%7.8%Millennial hours

10.6%12.1%1.5%15.4%12.6%GME expansion

12.3%13.6%3.3%16.8%14.5%Retire 2 yrs later

4.4%5.5%(4.6%)9.1%6.6%Retire 2 yrs earlier

8.7%9.8%(0.13%)13.5%10.8%Status Quo-no changein hours or age atretirement



PrimaryCare

Projections in the table are independent of each other. Impact would be additive for more thanone of the alternative scenarios: e.g., combined impact of delay in retirement plus “millennials”working fewer hours would result in an increase of less than 1% over the status quo projection,compared to a 12.3% increase for later retirement alone.

Overall percent increase in supply, 2013-2025, for each scenario

31

Projected Supply of Physicians, 2013-2025Complexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

32

Wisconsin Physician Supply in 2025:alternate scenarios applied to Wisconsin

Wisconsin physicians < age 65

58914(3)36Millennial + retire 2 yrs latercompared to 2025 status quo

12,80236452411168850582012 supply, physicians <65

(409)(130)(70)(59)(151)Millennial hourscompared to status quo

24782393295GME expansion compared to2025 status quo

4671398456187Retire 2 yrs latercompared to status quo

(549)(156)(109)(74)(210)Retire 2 yrs earlier comparedto status quo

13,9284003240819155602Projected 2025



PrimaryCare

Assumes that Wisconsin is able to recruit its share of the na'onal supply ofnew physicians.

33

. . . . .

Set aside the various supply scenarios andassume status quo supply, what is theimpact of the various demand scenarios?

34

Demand Projections for 2025

AAMC demand scenarios&

application to Wisconsin

35

Demand ScenariosComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

1. Changing demographics

2. Changing demographics + ACA medical insuranceexpansion

3. Changing demographics + ACA + managed care4. Changing demographics + increased use of retail clinics

5. Changing demographics + ACA + increased use ofadvanced prac'ce nurses (moderate prac'ce level)

6. Changing demographics + ACA + increased use ofadvanced prac'ce nurses (high prac'ce level)

36

Notes on the demand scenarios

• all scenarios include changing demographics from 2013-‐2025

• all but the first (status quo) include projected impact ofthe ACA

• other scenarios explore greater use of integrated caredelivery models, retail clinics, and APRNs

37

Notes (continued)Other considera'ons (discussed in the AAMC report, but not included in

the demand models):

• growth in supply of PAs,• trends in concierge primary care prac'ce,• immigra'on reform,• increased use of tele-‐health,• other new technology,• na'onal effort to reduce hospital admissions for ambulatory-‐sensi've

condi'ons and readmissions

Also -‐Did not model poten'al impact of increased demand for clinical teaching

to provide clinical sites for expanded medical school enrollment

38

Demand Scenarios - impact by specialty groupComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

8%

11%

13%

13%

13%

12%

OtherSpecialties

9%

13%

12%

21%

17%

15%

PrimaryCare

17%

19%

21%

16%

21%

20%


15%

16%

16%

18%

16%

13%

Surgery All

14%Changing demographics

11%Changing demographics + ACA +increased use of APRNs (highpractice level)

14%Changing demographics + ACA +increased use of APRNs(moderate level)

15%Changing demographics + ACA +increased use of retail clinics

17%Changing demographics + ACA +managed care

17%Changing demographics + ACAmedical insurance expansion

Demand Scenarios Impact - % growth in demand 2013-2025

AAMC Report, p. 26

39

Demand Scenarios - impact by specialty groupComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

4.4%

(0.7%)

3.0%

OtherSpecialties

13.1%

1.5%

7.6%

PrimaryCare

7.0%

2.6%

5.5%


18.2%

15.5%

13.0%

Surgery All

6.8%Changingdemographics only

9.3%Alternate scenarios,Highest estimate

3.7%Alternate scenarios,Lowest estimate

Projected increase (decrease) in demand by specialty, as % over (under) status quo supply

Derived from data in AAMC report

40

Projected DemandComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

41

Combining the Supply &Demand Projections

42

Projected Total Supply and DemandComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

43

Projected Total Physician ShortfallComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

44

Notes on the graphs

• Extreme high and low scenarios least likely tohappen -‐ mul'ple factors are likely to mi'gate thehighs and lows.

• 25th to 75th percen'le of the shortageprojec'ons reflects what they think is most likelyrange.

• Also modeled demand for each of the 4 specialtygroups

45

Supply and Demand - Primary Care PhysiciansComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

46

Projected Primary Care Physician ShortfallComplexities of Physician Supply and Demand: Projections from 2013 to 2025,

AAMC,March 2015

47

Notes on the scenarios by specialtygroup

• Scenarios 2&4 (changing demographics + ACA) hadhighest demand for Medical Subspecial'es and OtherSpecial'es

• Scenario 3 (changing demographics + ACA + managedcare) had highest demand for Primary Care and Surgery,and lowest demand for Medical Subspecial'es

• Scenario 6 changing demographics + ACA + high use ofAPRNs) had the lowest demand for Primary Care, Surgeryand Other Special'es and next lowest demand forMedical Subspecial'es

48

Notes (continued)

• Scenario 3 (managed care) had the highest demand forphysicians as a whole, but lowest demand for the MedicalSubspecial'es

• Scenario 6 (high use of APRNs) had the lowest overalldemand for physicians (but would have higher demandfor NPs and PAs)

49

Application to WisconsinModeling demand: population growth

• Wisconsin is projected to have lower popula'on growth overall (about 9%compared to 10% na'onally), but higher growth in the propor'on of thepopula'on over 65.

• Fiqeen coun'es are projected to lose popula'on by 2040 compared to 2010.These are mostly northern coun'es with higher percentages of older residentsand thus most affected by natural decrease over 'me, combined with lowernet in-‐migra'on.

• Eighteen coun'es are projected to grow through 2030, then decline inpopula'on as deaths exceed births, but will s'll have a net gain in 2040rela've to 2010.

• The remaining coun'es are projected to con'nue to grow through at least2035 through natural increase and net in-‐migra'on.

• Overall, the popula'on is projected to increase to 6,203,850 by 2025. Most ofthe growth will be in metropolitan areas and adjoining coun'es, and incoun'es with high rate of natural increase (Clark, Menominee, Trempealeau,Vernon)

Source: Wisconsin’s Future Population: Projections for the State, Its Counties and Municipalities, December 2013, David Egan-Robinson (UW-APL), prepared for Wisconsin Dept of Administration Demographic Services Center.

50

Application to WisconsinModeling demand (continued)

• Impact of health risk factors and chronic condi'ons might be higher for WI -‐this needs further analysis.

• The AAMC report projects that changing demographics (more elderly, withhigher prevalence of chronic disease) will likely increase demand for specialtycare at a faster rate than demand for primary care services. This couldchange with changes in care delivery for management of chronic disease, aswell as changes in the structure of deduc'bles and co-‐pays in Medicaresupplemental policies.

• The AAMC demand es'mate includes mee'ng the current shortage. Theirmethod would put our current shortage at 120 primary care physicians and40 psychiatrists (3.4% shortage in primary care and ~6.9% in psychiatry). Wehave a range of higher es'mates from DHS, Kaiser Founda'on and our ownwork. For the Wisconsin projec'on, suggest using 200 primary care physiciansand at least 200 psychiatrists as the current shortage es'mate.

51

Application to WisconsinWI Demand Projections - impact by specialty group

Estimated Demand due to:

23% - 29%

204-247

886

843

874

639

Psychiatry

698-1592(61)-108314-43850-134116-767Shortfall (Status QuoSupply)

15,5203471284620506369Highest estimate, otherdemand scenarios

2% - 7%

1965

2020

1915


(2%) - 3%

3302

3504

3364 all other

All OtherSpecialties

4% - 11%

14,625

15,103

13,928

All

11% - 16%2% - 13%Shortfall as % projecteddemand

27825718Lowest Estimate, otherdemand scenarios

27216063Changing demographics

24085602Estimated Supply 2025under status quo scenario

SurgeryPrimaryCare

*Assuming Wisconsin competes successfully for the available supply of new physicians**Includes filling current Wisconsin shortage estimated at 200 primary care physicians and 200 psychiatrists.Population basis for ratios: 5,686,986 in 2012, 6,203,850 in 2025

AAMC: 25th -‐ 75th percen'le of the range is most likely. Overall for Wisconsin thatwould be a shorYall of approximately 1145±224

52

WI Demand Projections by Service Area Type

4%-11%20%-29%18%-28%6%-14%3%-10%8%-15%3%-9%2%-7%Shortfall as %projected demand

698-1592

76-106161-23524-5123-6871-129272-75470-249Shortfall

15,52039090939075490283623544Highest estimate,other demandscenarios (#3)

14,62536083436270984581503365Lowest Estimate,other demandscenarios (#6)

15,10337687237673387384093464Changingdemographics

13,92828467333868677378783295Estimated Supply2025 under statusquo scenario

AllRural-‐

Hub <2500

Rural-‐

Hub >2500

Mixed-‐

Hub<10,000

Mixed-‐

Hub>10,000

UrbanMetroMetro-Academic

Note: Projections reflect specialty mix for each service area type, but do not account for localvariation in demographic factors. The increasing proportion of older individuals in the more ruralservice areas would likely increase demand during the period of this projection.

53

WI Demand Projections by Region

5-11%42-96854800828758La Crosse

8-14%64-118868814841749Eau Claire

13-20%27-45222204213177West Central

21-27%18-2591848866Superior

9-15%20-36246230238210Rhinelander

4-10%45-1161209113811751093Wausau

3-8%116-3734766451046554394Milwaukee

3-9%22-66772728750706Waukesha

9-14%56-98689648669592Southeast WI

3-8%75-2182597245325322379Madison

5-11%21-48450423436402Janesville

37-42%22-2866606338Southwest WI

7-13%18-37289270279252Fond du Lac

7-13%18-37282263273245Oshkosh

5-10%33-77753710732677Appleton

9-14%32-53357365376334Sheboygan

7-13%67-123980925952857Green Bay

Shortfall as %projecteddemand

ShortfallHighestestimate, otherdemandscenarios(#3)

Lowest Estimate, otherdemand scenarios(#6)

Changingdemographics

Estimated Supply2025 under status

quo scenario

Note: Southwest , West Central and Superior regions are also served by hospitals and physicians in other states (Dubuque IA. Minneapolis-St. Paul MN and Duluth MN, respectively)

54

Again . . .what might be different for WI that wehaven’t accounted for

Projec'on may overstate need as Wisconsin’s popula'on growth is expected to be lowerthan na'onal (9% compared to 10% used in AAMC projec'on).

On the other hand, projec'on may underes'mate demand in WI due to higherpropor'on of the popula'on over age 65. Higher burden of certain chronic diseases?

Demographic differences among the service areas and regions would affect the demandprojec'on. This quick applica'on of the AAMC scenarios does not include thesedifferences.

Are there differences in u'liza'on paTerns and/or organiza'on of primary care deliveryin Wisconsin (group prac'ce model, integrated insurance and provider organiza'ons,etc.) that might make Wisconsin more efficient? Has Wisconsin already seenchanges related to implementa'on of managed care projected in the na'onalmodel?

Differences in paTerns/hours of work between Wisconsin physicians and the groupAAMC used as reference (Florida physician licensure survey)?

Differences in implementa'on of ACA and expansion of Medicaid compared to otherstates.

Differences in supply and u'liza'on of physician assistants and nurse prac''oners

55

What will this look like to thoseresponsible for recruiting new

physicians?

56

New physicians needed 2013-2025due to current shortage, retirement and increase in demand

551-620117-13042-45107-11281-88203-253Average annual # of positions to fill

(2) - 3%

1525- 1694

408

239

361

1286

0

Otherspecialties

142361371277460OR: Additional needed fordemographic change and otherdemand scenarios -LOW ESTIMATE

23181044353621111OR: Additional needed fordemographic change and otherdemand scenarios -HIGH ESTIMATE

7164 - 8059541 - 5841388 - 14521057 - 11422638 - 3289TOTAL - Positions to fill 2013-2025under range of demand scenarios

4 - 11%23 - 29%11 - 16%2 - 7%2 -13%% potentially unable to fill due tonational supply shortfall

TOTALPsychiatry*Surgicalspecialties

Medical sub-specialties

Primary care

190192310332805Additional to meet demand due todemographic change

534128010177801978Projected retirements**

400200 (26%)00200 (4%)Current shortage

*Using same rate for Psychiatry as for Other Specialties. AAMC study does not provide separate rate for Psychiatry.**Using # reaching age 65 in 2012-2025 as estimate of full FTE retirements, assumes those retiring before 65 balanced bythose continuing to work past 65.

57

New Physicians Needed 2013-2025 by Service Area Type

18% -28%

41-47

533-607

146

72

110

315

146(19%)

Rural>2500

20% -29%

18-20

229-259

61

31

47

129

69(21%)

Rural<2500

551-62016-1828-3136-40300-337

113-126Average annual # of positionsto fill

6% -14%

210-238

61

33

47

159

18 (5%)

Mixed<10,000

14236982802335OR: Additional needed fordemographic change andother demand scenarios -LOW ESTIMATE

23181131391284514OR: Additional needed fordemographic change andother demand scenarios -HIGH ESTIMATE

7164-8059

363-407466-523

3901-4383

1463-1642TOTAL - Positions to fill2013-2025 under range ofdemand scenarios

4% -11%

3% -10%

8% -15%

3% -9%

2% -7%

% potentially unable to fill dueto national supply shortfall

TOTALMixed>10,000

UrbanMetroMetro-Academic

1901921101060434Additional to meet demanddue to demographic change

534128433529921127Projected retirements**

400(3%)

10 (2%)

49(6%)

107(1%)

1Current shortage

*Using same rate for Psychiatry as for Other Specialties. AAMC study does not provide separate rate for Psychiatry.**Using # reaching age 65 in 2012-2025 as estimate of full FTE retirements, assumes those retiring before 65 balanced bythose continuing to work past 65.

58

New Physicians Needed 2013-2025, by Region

5-11%32-36418-462 + 105 = 446+ 31427La Crosse

8-14%33-36425-468+ 106 = 452+ 30145Eau Claire

13-20%9-10112-125+ 27 = 121+ 7024West Central

21-27%559-64+ 11 = 62+ 3615Superior

9-15%11-12141-153+ 29 = 149+ 10416Rhinelander

4-10%46-51598-657+ 147 = 635+ 46622Wausau

3-8%161-1792094-2323+ 586 = 2239+161241Milwaukee

3-9%25-28330-366+ 92 = 352+ 2537Waukesha

9-14%27-29349-383+ 84 = 370+ 24640Southeast WI

3-8%84-941092-1218+ 320 = 1172+ 82230Madison

5-11%18-19229-251+ 55 = 242+ 17710Janesville

37-42%3-442-46+ 8 = 45+ 1720Southwest WI

7-13%12-13152-167+ 35 = 162+ 11512Fond du Lac

7-13%11-12145-160+ 34 = 155+ 10714Oshkosh

5-10%24-27315-351+ 92 = 337 + 22916Appleton

9-14%16-17202-221+ 49 = 214+ 14421Sheboygan

7-13%35-39461-506 + 120 = 488 + 32840Green Bay

% potentiallyunable to fill dueto national supplyshortfall

Averageannual # ofpositions to fill

OR: Total positions tofill 2013-2025 underrange of demandscenarios

+ Additional to meetdemand due todemographic change

+ Projectedretirements

(# reaching age65)

Currentshortage

Note: Southwest , West Central and Superior regions are also served by hospitals and physicians in other states(Dubuque IA. Minneapolis- St. Paul MN and Duluth MN, respectively)

59

What about the supplyscenarios?

60

Impact of workforce participation scenarios on potentialshortfall

5% - 11%(2%) - 3%24% - 29%11% - 16%2% - 7%2% - 13%Status quo shortfall as %projected demand

add 409add 108add 20add 69add 58add 150Millennial hours

add 549add 131add 25add 108add 74add 210 toshortfall

Retire 2 years earlier

(461)(116)(22)(83)(56)(184)Retire 2 years later -reduces # needed

(2)

204-347

639

541 - 584

Psychiatry

(52)(8)(14)add 2 toshortfall

(34)Retire 2 years later +millennial hours

698-1592(61)-108314-43850-134116-767Shortfall under status quoscenario

TOTALAll OtherSpecialties

Surgicalspecialties

Medicalsubspecialties

Primarycare

13,9283364240819155602Projected supply in 2025status quo supply scenario(assuming WI recruits itsshare)

7164 -7921

1525- 16941388 -1452

1057 - 11422638 -3289

DEMAND - Positions to fill2013-2025 under range ofdemand scenarios

61

Expand GME - a policy scenario

55771369221100111891798Total # GME graduates withexpansion

7150-81611525-1694541-5841388-14521057-11422638-3289Positions to fill 2013-2025

2476913393295GME expansion scenario**would add

68-78%81-90%38-41%69-72%104-112%55-68%Expanded GME as %projected demand

5330130020896211571703Est. # of graduates of WIGME programs 2012-2025, atcurrent number of slots

TOTALOtherspecialties

Psychiatry*Surgicalspecialties


Primary care

*Separate rate for Psychiatry not available. Used same rate as for Other Specialties.

** “The GME Expansion scenario is based on the proposed Resident Physician Shortage Reduction Act of 2013 and assumesincreasing Medicare supported GME slots by 3,000 annually between 2017 and 2021.” [AAMC, p. 6] Assumes all specialtiesgain the same proportion of slots.

But of course we don’t retain all the graduates of our GMEprograms, and . . .

62

Paradoxically -• GME training slots in Wisconsin meet the lowest

percentage of need in the specialties (primary care)that provide the bulk of the physician workforce inrural and mid-sized communities, and the specialty(psychiatry) where Wisconsin has the greatestcurrent shortage.

• Other specialties, where GME slots come closer tomatching projected need, are more urban-based andhospital-centered and likely easier to recruit fromGME programs in other states.

63

GME and new physician recruitmentTOTALOther

specialtiesPsychiatry*Surgical

specialtiesMedical sub-specialties

Primarycare

37%34%39%31%24%47%Estimated % retained from 1st 3yrs of GME*

100

117-130

410167489131Est. annual # of graduates of WIGME programs (based on 2013)

551-60942-45107-11281-88203-253Projected average annual # ofpositions to fill in Wisconsin 2013-2025

16%18%19%15%26%12%% licensed in WI more than 10years after graduation

48%

34%

Otherspecialties

46%43%54%50%41%% licensed in WI 3-10 years aftergraduation

37%39%31%24%47%Estimated % of current workforcewho completed first 3 years ofGME in WI (licensed in WI within 3yrs of graduation)

TOTALPsychiatry*Surgicalspecialties


Primarycare

Based on Wisconsin licensure information, see table below.

64

Summary

• AAMC:“Demand for physicians con'nues to grow faster than supply, leadingto a projected shorYall of between 46,100 and 90,400 physicians by2025.”-‐ overall shortage of 5%-‐11% of projected demand under various

scenarios

• WIProjected shorYall between 698 and 1592 physicians under the statusquo scenario ± 500 for the alternate supply scenarios-‐ projected overall shortage is 5-‐11%, but for service area types it ranges from 18-‐29% in rural areas to 2-‐15% in urban areas

65

WI (con'nued)• Shortage will be highest in primary care (2-‐13%), surgery (11-‐16%) and

psychiatry (24-‐29%)

• There will be an esGmated 762-‐866 posiGons to fill in rural serviceareas between 2013 and 2025, due primarily to physician reGrementand the increase in demand due to demographic factors. TheseposiGons are difficult to fill in the best of circumstances. The projectedshorMall in physician supply will mean that 18-‐29% of the demand forphysicians projected under these scenarios in rural areas will not bemet.

• This projecGon does not include the potenGal impact of UW and MCWrural program expansion for recruitment to pracGce in rural areas.That potenGal impact is unlikely to be fully realized without expansionof rural GME training programs.

66

How to meet the shortfall?

• Decrease the surplus popula'on (especially in Scrooge’sdemographic)?

• Repeal the ACA and limit access to care to those who can pay or haveinsurance at the workplace (our tried and true method of ra'oningaccess to care by the ability to pay)?

• Other financial incen'ves:– Pay physicians less so they will have to work longer before

re'rement?– Charge higher tui'on so young physicians will have to work longer

hours to pay off their student loans?

• Revise the projec'on with different assump'ons?

67

How to meet the shortfall? (seriously)• Strategic expansion of GME, as an aid to recruitment and to provide more access in

rural and underserved areas (rural GME, teaching health centers)

• Give serious aTen'on to factors affec'ng recruitment from our own GME programsand from other programs. What makes Wisconsin an aTrac've prac'ceenvironment? What makes the local community aTrac've?

• Are the incen'ves we have to aTract physicians to underserved areas effec've?How could they be improved? What else might be tried?

• What steps could be taken to encourage physicians to work longer beforere'rement? What are the impediments to maintaining a part-‐'me prac'ce?

• Aggressively pursue increased u'liza'on of APRNs and PAs in variety of care deliveryredesign and interprofessional/team-‐based prac'ce op'ons that prove effec've inimproving efficient u'liza'on of physicians and delivery of high quality health careservices.

• Expand use of community health workers and other strategies to reach vulnerablepopula'ons and improve chronic disease management .

68

More on the Expanded GMEScenario

• The AAMC expanded GME scenario assumed propor'onal expansionof slots in each specialty -‐ clearly that would be a mistake.

• Shiq of some posi'ons from subspecialty medicine to general internalmedicine? (At present, it looks like we train more subspecialtymedicine than we need in Wisconsin.)

• Assure that remaining subspecialty medicine slots are aligned to meetneeds of an aging popula'on.

• Strategic expansion of primary care residencies so residents train incommuni'es/sexngs where they are needed.

• Expand surgery residencies.

• Expand psychiatry residencies.

69

Also important . .• Assess any expansion needed in medical school enrollments in order

to

– fill the GME pipeline without increasing reliance on foreignmedical graduates

– assure that any medical school expansion is focused on admissionof qualified students who are most likely to prac'ce in rural andunderserved areas and in special'es where they are most needed

• Explore incen'ves that might encourage physicians to add to theirworkload in order to expand clinical training opportuni'es for thenext genera'on of physicians

70

More on recruitmentAAMC reports (April 2015) that the proposed 30 percent

first-year enrollment increase will soon be attained -an increase of 4946 1st year students over 2002-03.

71

AAMC data for Wisconsin on retention from UME andGME

37.9%Retained from UW and MCW combined

70.5%Retained from UME & GME combined

46.4%Retained from GME

33.4%Retained from UME - MCW

43.4%Retained from UME - UW

AAMC State Physician Workforce Data Book, November 2013

Of currently active physicians who trained in the state and arepracticing in the state:

An estimated 31.4% of currently active physicians who graduatedfrom UW or MCW did their residency in the state.

72

Recruitment from other states

2%2%2%2%2%1%Nebraska

2%2%2%3%2%1%Pennsylvania

2%2%2%3%3%1%Ohio

2%2%2%3%4%2%New York

3%4%4%3%3%3%Michigan

3%2%2%3%3%3%Missouri

16%

4%

4%

13%

17%

16%

16%

Other

20%19%20%18%13%All other states

4%4%4%2%5%Minnesota

4%

11%

13%

17%

18%

Psychiatry

100%Total

4%4%3%5%Iowa

13%15%12%12%Illinois

15%16%11%15%Wisconsin - MCW

16%16%12%18%Wisconsin - UW

17%7%27%20%International MedicalGraduates

TotalSurgicalSpecialties

SubspecialtyMedicine

PrimaryCare

Medical school location of physicians with address of record in WI as of 3-15-2012

Source: Wisconsin licensure data, 3-15-2012

73

Those states that dramatically expanded medical schoolenrollment have realized that they need to expand GMEin order to retain all those new grads in their state.

Wisconsin needs to think about how it will compete forthose graduates as well - either into Wisconsinresidencies, or post residency.

74

And on the demand side . . .Need to pursue long-‐term strategies:

• Popula'on health ini'a'ves to reducelong-‐term burden of disease

• Programs that address socio-‐economicdeterminants of health

75

Further research• Refine the demand projec'on with detail on Wisconsin demographics

(the microsimula'on method used in the March 2015 AAMC Report)

• BeTer understand the different configura'ons of special'es andhealth workforce that can be used to provide the services needed(the plas'city matrix approach used for forecas'ng on the ShepsCenter FutureDocs website)

• Understand fully how care delivery is organized locally so can we candecide which alterna'ves are the best fit (AAMC Local Area PhysicianWorkforce Modeling Project in progress)

• Understand the workforce implica'ons of emerging alterna've waysof implemen'ng interprofessional teams and integra'ng NPs and PAsinto a prac'ce.

76

Looking beyond 2025 . . .

Some coun'es (older, rural) will be losing popula'on due tonatural decrease and lack of in-‐migra'on. Will the demandpressure due to demographics ease?

Second half of the “baby boom” genera'on reaches age 65.

78

National projections and graphs are all fromThe Complexities of Physician Supply and Demand: Projections from

2013-2025, AAMC, March 2015https://www.aamc.org/download/426242/data/ihsreportdownload.pdf

For further information on the Wisconsin data, contact:Nancy Sugden

Assistant Dean, Academic Affairs, UWSMPHDirector, Wisconsin AHEC Program

[email protected]

or see the AHEC workforce webpage atwww.ahec.wisc.edu/workforce

Projection of Physician Supply and Demand in Wisconsin through … · Projection of Physician...

Documents

Transcript of Projection of Physician Supply and Demand in Wisconsin through … · Projection of Physician...