Increasing Physician Supply Research Articles

Individual and geospatial factors associated with receipt of colorectal cancer screening: a state-wide mixed-level analysis

BackgroundColorectal cancer (CRC) is the second leading cause of cancer death in US adults but can be reduced by screening. The roles of individual and contextual factors, and especially physician...

The Induced Productivity Decline Hypothesis: More Physicians, Higher Compensation and Fewer Services.

Public outrage regarding physician shortages during the past two decades have led to policies aimed at significantly increasing physician supply, yet access remains elusive. In this paper, we examine this puzzling trend and the causes underlying it by analyzing physician supply, compensation and productivity and the reasons behind productivity decline. We hypothesize that excess physician compensation beyond a target income induces productivity decline. In contrast to a wage–productivity gap for the average Canadian worker (where productivity has increased but compensation has not kept pace), physicians are experiencing a “reverse wage–productivity gap” whereby compensation is increasing but productivity is decreasing, resulting in more physicians, higher compensation and fewer services. We conclude by discussing potential policy options to address how best to provide timely access to medical care for Canadians while keeping physician healthcare expenditures at sustainable levels.

Disparities in Thyroid Screening and Medication Use in Quebec, Canada.

Background: No studies have examined the frequency of thyroid screening in the Canadian population, and whether thyroid screening and medication use vary by sex, race, income, and preexisting health conditions.Methods: Using data from the 2011, 2012 cycles of the Canadian Community Health Survey, we report rates of thyroid screening among Quebec residents ≥35 (n=7024) and rates of thyroid medication use among Quebec residents ≥35 (n=16,081). We examine variations in medication use and screening by sex, age, race, immigration status, access to a regular doctor, and health conditions that have been linked to thyroid disease.Results: Of the Quebec residents ≥35, 10.3% reported taking thyroid medication and 0.4% reported that the last blood test a physician ordered was to check for a new thyroid condition. Canadian-born residents and those who identified as White reported higher medication use and screening rates, compared to immigrants and those who identified as visible minorities. Racial disparities were especially pronounced, with White Quebec residents reporting three times greater odds of thyroid screening than visible minorities. The strongest predictors of both thyroid medication use and screening were access to a regular doctor. Despite women being eight times more likely to suffer from thyroid disease, women were not significantly more likely to be screened, compared to men (odds ratio=1.38, 95% confidence interval: 0.74–2.60).Discussion: Strategies are needed to decrease disparities in thyroid screening and medication use. Interventions that target health systems (e.g., increasing physician supply), providers (continuing professional education modules about thyroid disease for family physicians), and recipients of care (multilanguage public awareness campaigns and posters at walk-in clinics that describe common symptoms of different thyroid disorders) should be implemented and tested.

Rethinking the Obvious: Time for New Ideas on Medical Malpractice Tort Reform.

States have engaged in medical malpractice litigation reforms over the past 30 years to reduce malpractice insurance premiums, increase the supply of physicians, reduce the cost of health care, and increase efficiency. These reforms have included caps on noneconomic damages and legal procedural changes. Despite these reforms, health care costs in the United States remain among the highest in the world, provider shortages remain, and defensive medicine practices persist. The purpose of this study was to determine how successful traditional medical malpractice reforms have been at controlling medical costs, decreasing defensive medicine practices, lowering malpractice premiums, and reducing the frequency of medical malpractice litigation. Research has shown that direct reforms and aggressive damage caps have had the most significant impact on lowering malpractice premiums and increasing physician supply. Out of the metrics that were improved by malpractice reforms, similar improvements were shown because of quality reform measures. While traditional tort reforms have shown some targeted improvement, large-scale, system-wide change has not been realized, and thus it is time to consider alternative reforms.

Assessing the prospects for physician supply and demand in Canada: Wishing it was rocket science.

"It's not rocket science" is an often used phrase to describe tasks that are not very difficult. Although rocketry has proven to be an exacting science with highly predictable results, the same cannot be said for physician workforce planning in Canada. The "boom" in physician supply in the 1960s and 1970s was followed by a "bust" in the early 1990s and a further boom in the 2000s. A large generational shift in the physician population is anticipated between now and 2030; the proportion of "boomers" (1946-1964) will drop from 43% to 16% of the practising profession. Canada has not been alone in increasing physician supply. Any judgement as to whether too many or too few physicians are being trained must consider the drivers and mitigators of both supply and demand. Although there are current concerns about a shortage of practice opportunities for some specialties, the available data do not indicate a physician surplus on the horizon in Canada.

Medical guidelines, physician density, and quality of care: evidence from German SHARE data

We use German SHARE data to study the relationship between district general practitioner density and the quality of preventive care provided to older adults. We measure physician quality of care as the degree of adherence to medical guidelines (for the management of risk factors for cardiovascular disease and the prevention of falls) as reported by patients. Contrary to theoretical expectations, we find only weak and insignificant effects of physician density on quality of care. Our results shed doubt on the notion that increasing physician supply will increase the quality of care provided in Germany's present health care system.

Higher Physician Density is Associated with Lower Incidence of Late-stage Colorectal Cancer

Colorectal cancer (CRC) is the third most common cancer in the United States and a leading cause of cancer related mortality. Routine screening decreases incidence and mortality; however rates of screening remain low. Physician recommendation is a key determinant of screening rates; thus, physician availability may also influence CRC incidence and mortality. Data on CRC incidence and stage at diagnosis was obtained for each county in Pennsylvania from the Pennsylvania cancer registry. Physician density (per 100,000 population) was calculated for each county using physician counts from the American Medical Association. Pearson correlation coefficients and linear regression models were used to examine the association between physician density and CRC incidence and outcomes. Primary care physician density (Pearson's correlation coefficient: -0.25, p=0.05) and gastroenterologist density (correlation coefficient -0.25, p=0.04) inversely correlated with county-level incidence of late-stage CRC. However, this association was seen only in non-metropolitan counties or those with low population density. On linear regression, non-metropolitan counties which had a high density of gastroenterologists had an incidence of late-stage CRC that was lower by 4/100,000 (reduction of 14%). Low population density counties had lower incidence of late-stage CRC by 5/100,000 (reduction of 17%) when they had at least 3.3 gastroenterologists/100,000 population compared to counties with a lower gastroenterologist-per-population ratio. Gastroenterologist density did not correlate with reduced late-stage CRC incidence prior to institution of Medicare coverage for colonoscopy for routine CRC screening. Higher gastroenterologist or PCP density is associated with 14-17% lower incidence of late-stage CRC in non-metropolitan counties or those with low population density. Efforts at increasing physician supply should target these underserved areas.

Building a Diverse Physician Workforce

THE ARTICLE BY GRUMBACH AND CHEN IN THIS ISSUE of JAMA confirms that postbaccalaureate programs are an effective means for increasing minority and disadvantaged students’ acceptance to medical schools. These findings are timely, because the medical profession in the United States is in great need of documented ways to achieve substantially more racial and ethnic diversity. Absent sufficient diversity, medicine simply cannot fulfill its obligation to provide optimum health care services to everyone. In 2005, only 1043 US medical school graduates were black, only 936 were Hispanic/Latino, and only 96 were Native American. In aggregate, these graduates comprised fewer than 13% of all graduating MDs that year. That value is about half of the representation of these minority groups in the US population—a population that is increasingly diverse. Grumbach and Chen’s findings are especially noteworthy because the University of California, the setting for their research, has been denied the use of affirmative action programs in medical school admissions since the 1996 passage of Proposition 209. This was a ballot initiative amending the state’s constitution to prohibit preferences based on race and sex in public contracting, employment, and education. One result is that the percentage of underrepresented minorities matriculating to California medical schools dropped from a high of 21.99% in 1992 to 15.6% in 2000. Consequently, this study offers an important approach to satisfying the 2003 Supreme Court ruling in Grutter v Bollinger et al, which called for institutions intent on using raceconscious admission policies to make a “serious, good faith consideration of workable race-neutral alternatives that will achieve the diversity the university seeks.” Justice O’Connor’s majority opinion in this case expressed the expectation that “25 years from now, the use of racial preferences will no longer be necessary.” To meet that deadline, much more research on the effectiveness of race-neutral alternatives to affirmative action is needed. Using California as their “laboratory,” Grumbach and Chen also offer a preview of the nation’s not-too-distant future. In this state, where “minority” populations are now in the majority, only 139—or just under 14%—of all California medical school graduates in 2005 were black, Native American, or Hispanic/Latino. This must be considered in the context of the California Wellness Foundation’s prediction that the state will experience “a shortfall of approximately 17,000 doctors by 2015.” Earlier this year, the Association of American Medical Colleges (AAMC) called for a 30% increase in enrollment at Liaison Committee on Medical Education–accredited medical schools by the year 2015 to offset the impending shortage of physicians nationwide. Implementing this increase will be a monumental undertaking. Doing so while remaining committed to increasing the racial and ethnic diversity of the entering medical school classes will be doubly difficult. But increasing physician supply and increasing diversity are both critically important and inseparable goals. Health care disparities, inadequate access to care, and gaps in the quality of care will only worsen if a larger physician workforce in the future is no more diverse than it is today. Preparing tomorrow’s physicians means substantially increasing the efforts to locate, encourage, and support talented and capable young people from diverse backgrounds and cultures who are willing and prepared to pursue careers in medicine. Postbaccalaureate programs are designed to prepare college graduates to succeed in applying to medical school, but they differ widely in size, format, curricula, and mission. Many are committed to increasing minority and disadvantaged students’ representation in medical school. Wayne State University School of Medicine established the nation’s first such program 37 years ago, enrolling black students who had initially been rejected by the school. After 1978, the program opened enrollment to all racial and ethnic groups. By 1997, 160 (83%) black students and 51 (94%) of other races/ethnicities who graduated from the program between 1969 and 1992 had completed medical school. Strengthening programs that reach minority students earlier in their education is also crucial; indeed, it is an essential strategy for closing medicine’s diversity gap permanently. Socalled “pipeline” programs refer to elementary school and high

Physician supply, supplier‐induced demand and competition: empirical evidence from a single‐payer system

We examined the earnings of 8106 office-based (FTE) physicians in 2002 in Taiwan for evidence of supplier-induced demand (SID). We hypothesize that SID, operating in the form of mutual cross-specialty referral, will cause earnings to increase with total physician density (all specialties taken together), but simultaneously, decrease with increasing competition within specialties. We used multiple regression analyses controlling for high-user population, physician demographics and practice type. The evidence supports our hypotheses. Increasing total physician density (all specialties) is positively associated with earnings. Concurrently, within specialties, increased competition is associated with reduced earnings. The medical appropriateness of increasing health care utilization with increasing physician supply cannot be directly determined from the data. However, evidence of a steady earnings increase with increasing total physician density, which precludes a saturation point (of appropriate care levels) at some optimum physician density, substantiates SID in the office-based practice market. Empirically, our data suggest that the average market effect of physicians on one another is synergic when all specialties are considered together, but competitive within each specialty.

Impact of Malpractice Reforms on the Supply of Physician Services

Proponents of restrictions on malpractice lawsuits claim that tort reform will improve access to medical care. To estimate the effects of changes in state malpractice law on the supply of physicians. Differences-in-differences regression analysis that matched data on the number of physicians in each state between 1985 and 2001 from the American Medical Association's Physician Masterfile with data on state tort laws and state demographic, political, population, and health care market characteristics. Effect on physician supply of "direct" malpractice reforms that reduce the size of awards (eg, caps on damages). The adoption of "direct" malpractice reforms led to greater growth in the overall supply of physicians. Three years after adoption, direct reforms increased physician supply by 3.3%, controlling for fixed differences across states, population, states' health care market and political characteristics, and other differences in malpractice law. Direct reforms had a larger effect on the supply of nongroup vs group physicians, on the supply of most (but not all) specialties with high malpractice insurance premiums, on states with high levels of managed care, and on supply through retirements and entries than through the propensity of physicians to move between states. Direct reforms had similar effects on less experienced and more experienced physicians. Tort reform increased physician supply. Further research is needed to determine whether reform-induced increases in physician supply benefited patients.

Experiences of Organization for Economic Cooperation and Development countries with recruiting and retaining physicians in rural areas.

This present study discusses the potential pitfalls in measuring physician shortages in rural areas and presents existing evidence of the effectiveness of policy interventions designed to influence the geographical distribution of physicians. Information on the geographical distribution of physicians was derived from a survey of Organization for Economic Cooperation and Development (OECD) countries and a desk review of the academic literature and policy documents of OECD governments. Whether policies have been effective in recruiting and retaining physicians in rural areas. Existing measures of physician shortages in rural areas may be misleading as they do not account for a number of supply side factors (e.g. physician productivity, mobility of physicians across areas) and demand-side factors (e.g. patient needs for physician services). Increases in the national number of physicians have narrowed, but not eliminated, shortages in rural areas. Some success in increasing physician supply to rural areas has been reported with educational, regulatory and financial policies; whereas countries' experiences with education-related funding policies are mixed. There is some evidence suggesting that the effectiveness of these policies can be enhanced by supporting occupational opportunities for the spouse/partner, education of children and accommodation. Although there has been little evaluation of policy interventions, physician shortages in rural areas may be reduced by supply side policies that focus on the physician in combination with measures to sustain the economic and social viability of rural communities.

Increasing physician supply in medically underserved areas

Physician supply in medically underserved areas has long been an interest of health and labor economists. I employ a rich database containing the location of physicians at 5-year intervals to compare the types of locations chosen by alumni and nonalumni of a United States program charged with increasing physician supply. Using a multinomial logit model with discrete unobserved heterogeneity to account for endogeneity of enrollment in the program, I find that eliminating the program would decrease the supply of physicians in medically underserved communities by roughly 10%.

Effects of physician supply on early detection of breast cancer.

There are few studies examining the effects of physician supply on health-related outcomes. We hypothesized that increasing physician supply and, in particular, increasing primary care supply would be related to earlier detection of breast cancer. Information on incident cases of breast cancer occurring in Florida in 1994 (n = 11,740) was collected from the state cancer registry. Measures of physician supply were obtained from the 1994 AMA Physician Masterfile. The effects of physician supply on the odds of late-stage diagnosis were examined using multiple logistic regression. There was no relation between overall physician supply and stage of breast cancer of diagnosis. Each 10th percentile increase in primary care physician supply, however, resulted in a 4% increase in the odds of early-stage diagnosis (adjusted odds ratio = 1.04, 95% confidence interval = 1.01-1.06). The supply of primary care physicians was significantly associated with earlier stage of breast cancer at diagnosis. This study suggests that an appropriate balance of primary care and specialty physician supply might be an important predictor of health outcomes.

The Supply of Primary Care Physicians

To the Editor. —Recently, much has been written about the paucity of young physicians entering primary care specialties. A recent article by Politzer et al 1 indicated that the primary emphasis for increasing physician supply ought to be at the level of medical education training. This analysis completely missed the main reason why more physicians have not entered primary care specialties. The reason is life-style. Three primary life-style factors that discourage more physicians from entering primary care include the following: (1) being on call; (2) finances; and (3) spouses. To elaborate, the on-call schedule of primary care physicians is, in most circumstances, far more rigorous than that for specialists. The type of work that is done on call is often performed for little financial reward. Second, the finances of primary care physicians are such that most can prolong their medical education from 8 to 9 or 10 years, counting medical

The political economy of medical underemployment in Mexico: Corporatism, economic crisis and reform

There seem to be periods in human history when a worldwide phenomenon affects countries at the most varied levels of economic development. In recent decades one of these phenomena has been the appearance of fundamental manpower imbalances in the health field. Such imbalances have adopted many forms, from geographic maldistribution to functional disparities among various personnel categories [3]. Of all these forms, probably the most prevalent has been the increase in the supply of physicians beyond the needs of the population, the capacity of the health care system to absorb them, or both. It is indeed a challenge to social, political and economic theory to explain the processes through which widely differing national circumstances can lead to such a similar result. While the problem itself of increased physician supply is shared by many countries, the social response has varied substantially across them. Some societies have been able to cope with the excess of physicians by diverse mechanisms, such as the reduction of working hours, the displacement of nonmedical providers, the growing medicalization of life, the encouragement of medical out-migration, or even the deliberate and planned export of physicians. In other countries, however, it has been impossible to fully utilize the increased supply of doctors. Probably the worst outcome has been the coexistence of underemployed physicians with large groups of people who lack ready access to medical services. This is the most extreme contradiction facing today the health care systems of many Latin American countries, Mexico among them. A survey carried out in 1986 revealed that 23 500 of the 81000 active physicians living in the 16 major cities of Mexico were unor underemployed [14]. At the same time, official statistics placed at 9.3 million (or 11% of the national population) the number of people without permanent health services (Ref. 7, p. 74). How did Mexico arrive to this state of affairs, which is obviously opposite

Physician distribution and health manpower policy in Korea.

This research studied the impact of increased physician supply on geographical distribution and identified the variables, both demographic and socio-economic, that account for physician maldistribution between urban and rural areas. Increased physician supply did not necessarily improve physician availability and access to health care in many rural and inner-city areas of Korea. Observed performance indicates that most physicians newly qualified since 1974 chose to work in major urban areas, while most rural areas had a shortage of physicians and health facilities. Physicians also tended to work in areas where there were supportive medical facilities, where the distance to major metropolitan areas was not great, where medical schools were located or nearby, and where consumers lived in pleasant surroundings.

The need for more physicians.

The Winter 1986 issue of Health Affairs contained several articles that relate to the “surplus” of physicians. These articles, especially “Impact of Increasing Physician Supply” by Harold Luft and Peter Arno and “How Many Doctors Are Enough?” by Jeffrey Harris, should be read by those who want to constrain supply. Harris is correct that we do not have definitive methodology for assessing optimal health personnel supply, particularly in an era of rapid public and private policy changes. I agree with his arguments and those of Luft. The changes in the organization, delivery, and financing of care are altering market dynamics, particularly physicians’ ability to induce demand to raise fees, and to protect income levels. In fact, the changes in organization, delivery, and financing would not have been possible without the increase in the supply of physicians and physician-to-population ratios. For example, less than a decade ago, health maintenance organizations (HMOs) showed little growth because of the lack of physician availability and physician opposition to organized and salaried practice; Factors affecting physician supply. In addition to the arguments cited in the Harris article, there are other factors affecting physician supply. First, productivity of physicians may be changing with the increase in salaried practice, increase in two-earner physician families, increase in female physicians, and, according to anecdotal information, earlier physician retirement. Second, as the “Trends in Health Personnel” DataWatch in the Winter 1986 Health Affairs points out, there is still a shortage of minority physicians, and the picture has worsened for blacks aspiring to attend medical school. The picture is also bleak for aspirants from lower-income families because of the rapidly rising costs of medical education and the decline of subsidized student aid. Numerous studies show that minority physicians are more likely to practice among underserved populations. A deliberate effort to reduce medical school enrollment will have further negative

Recent trends in pediatrician participation in Medicaid.

Many Medicaid policy changes occurred in recent years including those resulting from the Omnibus Budget Reconciliation Act of 1981 and the Tax Equity and Fiscal Responsibility Act of 1982. At the same time, the supply of providers increased and the health care market became more competitive. This paper presents evidence about how these developments are affecting pediatricians' participation in state Medicaid programs. Surveys conducted in 1978 (N = 814) and 1983 (N = 791) indicate that the proportion participating declined only slightly from 85.1% to 82.0%. The average Medicaid case load of participants remained at 15%, although extent of participation of individual pediatricians fluctuated. Previous research demonstrates that physicians' Medicaid participation is affected by reimbursement level, administrative complexity, and generosity of eligibility and benefits. Our data confirm these influences. However, the longitudinal design of the analyses reported here also captures shifts in the relative influence of these factors. The influence of policy factors has diminished over time, while the influence of changes in physician supply has increased. Increased physician supply, however, is associated with decreased Medicaid participation. Thus, diminished access to pediatric care for low-income children may result from recent changes in Medicaid and in the broader health care environment.

Does increased physician supply affect quality of care?

Prologue: One unsettling question facing the U.S. health care system today is whether, amidst the flurry of cost cutting, the quality of medical care is beginning to suffer. There is no real consensus about what good care is, but various organizations are actively striving to find out A crucial question in this determination of quality is how the growing number of physicians will affect it; since physicians are the basic building block for medical care, how they respond to changes around them is important Do more physicians mean that they will provide better care because they are more accessible, have more time, and must compete more aggressively? Or do more physicians mean extra lab tests, unnecessary surgery, and too many office visits for the patient? James Perrin and Joseph Valvona attempt to answer these questions through a review of past research and a new analysis of their own. They assert that simply increasing the number of physicians will not improve the quality of health care. While doing so ma...

Impact of increasing physician supply: a scenario for the future.

Prologue: The ratio of physicians to population has increased sharply over the last two decades as a consequence of federal and state policies that have encouraged the education of more medical doctors. But controversy stalks the question over what this increasing supply means to the future configuration of American medical care. In this article, economists Harold Luft and Peter Arno take a different perspective than most of their professional colleagues who have addressed the issue of physician supply. They argue that in today's rapidly changing health care environment it is not useful to take econometrically based models of physician supply that are based on past experience and project them into the future to determine implications for cost, access, quality, and other health policy issues. While projections of the impact of growing numbers of physicians on the U.S. health care system are needed, Luft and Arno offer some alternative models and scenarios for making these predictions. They argue that a combination of models provides a better starting point for discussions of future implications. Luft, who is professor of health economics at the Institute for Health Policy Studies in the University of California, San Francisco (UCSF) School of Medicine, received his doctorate in economics from Harvard University. He worked at the postdoctoral level at the Harvard Center for Community Health and Medical Care and spent five years as an assistant professor at Stanford before joining UCSF. Arno is assistant professor of health care administration at Baruch College/Mt. Sinai Medical School at City University of New York. He received his doctorate in economics from the New School for Social Research and worked as a Pew Postdoctoral Fellow at the UCSF Institute for Health Policy Studies.