Revisiting Accepted Physician Ratios
Healthcare organizations have perceived physician-to-population ratios published by the Graduate Medical Education National Advisory Committee to be the “gold standard” for determining physician demand by specialty. However, due to changes in the economic and regulatory climate, demographic composition of the U.S. population, and emerging new care models, using GMENAC ratios originally formulated in 1990 to project physician need in today’s healthcare environment may lead to the wrong conclusions.
When developing a physician needs study, one should apply several key adjustments to the provider inventory and the GMENAC physician-to-population ratios to reflect the following six characteristics:
1. Physicians Retiring Later. Due to the Great Recession, many physicians experienced substantial declines in net worth. As a consequence, they have postponed retirement and are staying in active practice longer, often until their early seventies. According to the American Medical Association, in 2012, approximately 42% of the nation’s 1 million physicians were 55 years or older and 21% were 65 years or older, up from 35% and 18%, respectively, in 2006.
2. Increased Role of Advanced Practitioners. The increased use of advanced practitioners or mid-level providers (nurse practitioners, physician assistants) in both office and hospital settings has altered the historic demand for physicians.
3. Aging U.S. Population. The aging U.S. population has and will continue to impact the demand for physician services, particularly in specialties such as primary care, cardiovascular services, gastroenterology, orthopedics, neurosciences, pulmonology, and urology. The 1990 GMENAC ratios do not account for the generational shift of the Baby Boomers into the 65 and up age cohort, or the fact that this generation typically has higher rates of obesity and chronic disease (e.g., cardiovascular, oncology) than previous generations.
4. Healthcare Reform Initiatives. The demand for primary care physicians will significantly increase as a result of healthcare reform initiatives, which are closely tied to the value of disease management and care coordination. Following patients through the care continuum as a means to better manage population health and curb preventable hospitalizations will put a greater emphasis on primary care physicians, who will increasingly act more as care coordinators and managers of their patients’ chronic diseases. A variety of clinically-integrated provider arrangements have and will continue to emerge to manage population health (e.g., bundled payment initiatives, accountable care organizations, etc.).
5. Insurance Mandate/Health Insurance Exchanges. A number of Affordable Care Act initiatives have been implemented that will increase the demand for physician services. The expansion of Medicaid, the insurance mandate, and the federal and state-operated insurance exchanges will expand the insured patient base, which is projected to drive up the demand for physicians, notably primary care physicians.
6. Hospitalist Programs. More hospitals/health systems are employing the use of hospitalist, intensivist, and laborist programs. Their successful implementation and the number of physicians utilizing those programs can reduce the community need for physicians if physicians use time they would otherwise be rounding to see patients in their offices. The way in which ratios should be adjusted to account for an organization’s hospitalist program(s) will be dependent on a number of factors: the hospitalist program’s success in managing the care of patients in the hospital; the percentage of primary care and medical specialists admitting through the hospitalist program; and whether physicians have expanded patient capacity due to time saved.
Considering the above indicators will help establish a physician supply and demand model that more accurately reflects how medicine is practiced today. It is essential that when considering the impact of the above six indicators, the hospital must provide adequate sourcing and documentation to withstand legal review, should it occur. It is important to note that adjusting the demand projection methodology to account for these variables is not a one-time fix to the 1990 GMENAC ratios. As organizations move forward, the relative role of each of the six variables will change, particularly as the use of telemedicine and retail clinics continue to grow and impact healthcare delivery.
Mark Dubow is a senior vice president with The Camden Group, an El Segundo-based healthcare consulting firm.
