1. POTENTIAL SOLUTIONS for the EVOLVING PHYSICIAN SHORTAGE POTENTIAL SOLUTIONS for the EVOLVING PHYSICIAN SHORTAGE Richard A. Cooper, M.D. Florida Board of Governors Orlando March 17, 2004

2. POTENTIAL SOLUTIONS ---------------------------------------------------------------------------------------- Expand the infrastructure for undergraduate medical education ---------------------------------------------------------------------------------------- Expand the applicant pool ---------------------------------------------------------------------------------------- Expand residency (GME) training programs ---------------------------------------------------------------------------------------- Increase the number of International Medical Graduates ---------------------------------------------------------------------------------------- Increase the utilization of nonphysician clinicians ---------------------------------------------------------------------------------------- Streamline the processes of care ---------------------------------------------------------------------------------------- Improve the legal and regulatory environment for medical practice ----------------------------------------------------------------------------------------

3. EXPANSION OF MEDICAL SCHOOLS

4. MEDICAL SCHOOLS, MATRICULANTS and GRADUATES, 1940-2002 Allopathic and Osteopathic 1935-1940 = 1.0

5. CONTRIBUTIONS TO INCREASED NUMBERS OF MD MATRICULANTS AND GRADUATES, 1960 vs. 1980 54% 45% 40% 46% 15%

6. DEANS’ SURVEY EXPANSION CAPACITY OF EXISTING MEDICAL SCHOOLS

7. SATELLITES and BRANCHES

8. SATELLITE CAMPUSES Expand educational capacity of school Distant from main campus Separate administrative structure Significant educational components Most developed in 1960s and 1970s 28 schools with satellite clinical campuses 6 schools with satellite preclinical campuses 6 schools with satellite preclinical campuses

9. BRANCH CAMPUSES ALLOPATHIC MEDICAL SCHOOLS U of I branch at Urbana, Rockford, Peoria Cleveland clinic branch of Case-Western Reserve OSTEOPATHIC MEDICAL SCHOOLS Touro University (CA) branch at Las Vegas, NV Philadelphia COM (PA) branch at Atlanta, GA Lake Erie COM (PA) branch at Bradenton, FL Western University (CA) branch planned ? where

10. APPLICANTS

11. BACHELOR’S GRADUATES and MEDICAL APPLICANTS 1940-2001 NCES/AAMC Medical Applicants - -50,000 -40,000 -30,000 -20,000 -10,000 - 0

12. NCES, Table 171 BACHELOR’S DEGREES 1920 to 2000 GI Bill 2.0M of the 3.4M who attended institutions of higher education under the GI Bill 1945-1965 Vietnam Draft ~1M (14%) of the 7M men who attended college during the Vietnam draft 1963-1978

13. AAMC/NCES FIRST-TIME ALLOPATHIC MEDICAL SCHOOL APPLICANTS as a PERCENTAGE of BACCALAUREATE DEGREES 1961-2001

14. WHITE MALE BACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTS 1977-2000

15. WHITE FEMALE BACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTS 1977-2000

16. ASIAN BACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTS 1977-2000

17. BLACK BACHELOR’S DEGREES AND FIRST-TIME MEDICAL APPLICANTS 1977-2000

18. STUDENTS MUST GRADUATE FROM HIGH SCHOOL TO GO TO COLLEGE ….BUT EVEN THEN, THEY MIGHT NOT

19. Census Bureau Table A-5 HIGH SCHOOL COMPLETERS 1967-2000

20. BACHELOR’S DEGREES PER CAPITA Per 1,000 21-year olds

21. RELATIVE PROPORTIONS of WHITES, ASIANS, BLACKS and HISPANICS VARIOUS LEVELS OF EDUCATION, 1999-2000 Bureau of the Census, NCES, AAMC

22. BACHELOR’S GRADUATES 1961-2001 and projected to 2012 NCES Projected

23. FIRST-TIME MD APPLICANTS 1961-2001 and extrapolated to 2020 Smoothed Trend Sufficient for 5,000 additional medicalschoolacceptances at the margin

24. 1. Creating sufficient numbers of high quality positions. 2. Limitations of Balanced Budget Act of 1997” Positions frozen at 1996 levels. 3. Budget implications of additional positions: Each new PGY-1 position will obligate Medicare to $35,000 in DME payments per year for an average of 4.5 years). 5,000 positions = $800M If IME payments are also allowed, each new first year position will obligate Medicare to an additional $75,000 for 4.5 years. 5,000 positions = $1.5B Total increase in Medicare GME at current rates would be: 5,000 positions = $2.3B GME CHALLENGES ------------------------------------

25. INTERNATIONAL MEDICAL GRADUATES

26. IMGs (all years) Citizenship or Visa Status Corrected for unknown

27. NON-US IMGs India, No Africa, Middle East vs the Rest of the World

28. Concerns US-IMGs vs. Foreign IMGs Quality of educational programs Rate of disciplinary actions Hurdles USMLE Steps 1, 2, 3 Clinical Skills Assessment (CSA) (cost, time) Visas to take CSA exam Visas to enter for residency Decreased availability of H1b visas (195K in 2003  65K in 2004) Competition England Canada Attractiveness of native countries IMG CHALLENGES

29. POTENTIALS and LIMITATIONS of NONPHYSICIAN CLINICIANS

30. OVERLAPPING RESPONSIBILITIES OF PHYSICIANS AND NONPHYSICIAN CLINICIANS COMPLEX CARE MULTISYSTEM DISEASE CARE CHRONIC DISEASE MANAGEMENT MINOR and SELF-LIMITED DISORDERS SYMPTOM CONTROL WELLNESS CARE and PREVENTION COUNSELING and EDUCATION NONPHYSICIAN CLINICIANS PHYSICIANS

31. PROCESSES of CARE Better information management Streamlined flow of care Safer technologies vs. Onerous federal regulation Intrusive managed care review Crippling malpractice litigation (Tort reform)

32. TIME FRAME OF POTENTIAL IMPACT ---------------------------------------------------------------------------------------- 10-15 Expand the infrastructure for undergraduate medical education ---------------------------------------------------------------------------------------- 10-15 Expand the applicant pool ---------------------------------------------------------------------------------------- 5-10 Expand residency (GME) training programs ---------------------------------------------------------------------------------------- 5-10 Increase the number of International Medical Graduates ---------------------------------------------------------------------------------------- 5-10 Increase the utilization of nonphysician clinicians ---------------------------------------------------------------------------------------- Now Streamline the processes of care ---------------------------------------------------------------------------------------- Now Improve the legal and regulatory environment for medical practice ----------------------------------------------------------------------------------------

33. RECOMMENDATIONS_______________________________________________ Begin immediately to expand the infrastructure for undergraduate medical education. Begin immediately to expand the infrastructure for undergraduate medical education. Expand residency training opportunities, especially in the non-primary care specialties. Expand residency training opportunities, especially in the non-primary care specialties. Foster continued development of opportunities for NPs and other NPCs, particularly in primary care. Foster continued development of opportunities for NPs and other NPCs, particularly in primary care. Examine the global impact of a continued dependence on IMGs. Examine the global impact of a continued dependence on IMGs. Review the factors that affect practice efficiency and professional satisfaction among physicians. Review the factors that affect practice efficiency and professional satisfaction among physicians.

34. Thank you.