Peer Review the Complexities of Physician Supply and Demand Projection From 2013 to 2025

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Over the past 15 years, policy reports and news headlines take predicted dire physician shortages.^i-four But if workforce projections included a realistic assessment of the roles of NPs and md assistants (PAs), these loftier-profile concerns over the supply of physicians might seem considerably less dramatic.

Healthcare workforce projections conduct crucial policy implications. Provider shortages can shortchange patients, and overproduction imposes costs on society. Investments in medical education deport high cost tags, often paid for by the public.⁵ Overproduction potentially is devastating to new trainees, who might not be able to secure employment—a pressing business not only for physicians just likewise for the NP and PA professions, which are experiencing unprecedented growth.^6,7 And supplier-induced demand can raise the overall cost of healthcare if increased availability of services causes patients to use healthcare more than might be justified by their health problems.^{half-dozen,viii}

The Association of American Medical Colleges (AAMC) commissions the well-nigh publicized physician supply and need projections on an annual basis. Its 2019 update continued to predict large shortages of physicians: between 46,900 and 121,900 by 2032.⁹ The well-nigh recent iterations of the AAMC study improved over the initial ones by factoring NPs and PAs into its projections. The projected scenarios that include NPs and PAs anticipate a narrower gap betwixt doc supply and demand.

The microsimulation techniques used in the AAMC projections allow use of a range of assumptions to produce a corresponding range of projections—a reasonable arroyo to incorporating uncertainties in the healthcare environment. The updated AAMC study models the effect of adding NPs and PAs to the provider mix using a moderate and loftier estimate of the proportion of a dr.'s labor that an NP or PA tin supervene upon. The AAMC uses estimates of 25% in primary care, 15% in medical subspecialties, and 10% in surgical subspecialties; the loftier estimates are twice these portions.

Unfortunately, fifty-fifty the "high" commutation ratios that the AAMC chose to apply for NPs and PAs are unrealistically low. The written report includes no references that support these ratios, and the AAMC did non respond to my request for whatsoever literature it used to select the ratios for the forecasting models. AAMC administrators defend these ratios by suggesting that NPs and PAs often are used to perform clinical tasks that would otherwise not have been provided to patients. If this is true, they argue, PAs and NPs are not just replacing physician labor for some tasks, but also calculation to the basket of services provided.¹⁰ Following this logic, the substitution ratio of NPs and PAs, compared with physicians, should be low. For example, if a PA or NP is available, they might be used for all-encompassing patient instruction or for additional follow-up visits that the physician would not have otherwise performed. Although anecdotal reports exist of these uses of PAs, published research suggests that this is non the norm. For instance, in a comparing of patients cared for with and without a PA involved, using data from the federal nationally representative Medical Expenditure Panel Survey, adjusting for patient complexity and analyzing over a one-year period of intendance, patients who had PA involvement did not take higher apply of function visits.¹¹ A number of boosted analyses from national samples show that although patients seen by physicians tend to be slightly older and less healthy than patients seen past NPs and PAs, the patient populations and patient intendance tasks of PAs and NPs are generally like to those of physicians.^12-20

Although the AAMC projections use a substitution ratio of 25% for PAs and NPs in their "status quo" projections, the weight of evidence points to a reasonable primary intendance substitution ratio at or to a higher place 75%.^21-25 Of particular note, in 2011, the Secretary of Health and Human being Services convened an interprofessional committee comprising 29 experts to review available show and advise the secretarial assistant on guidelines for determining health professions shortage areas (HPSAs). Ane of the fundamental questions posed to this commission was the appropriate method of bookkeeping for NP and PA contributions to primary care. The committee deliberated for 36 days over xiv months and concluded that a reasonable substitution ratio for the purpose of determining HPSA status was 75%. To use a higher ratio, the committee commented, might disadvantage areas that rely heavily on NPs, PAs, and nurse-midwives because scope-of-practise limitations forestall them from supplying the full range of services in some states.²³

Moreover, back-of-the-envelope calculations provide an intuitive argument. If the productivity of NPs and PAs was as low as indicated in the AAMC'due south "high" scenario, it would not be profitable to hire them. Strong employer demand for NPs and PAs and wage increases that persistently exceed inflation suggest that this is not the case.²⁶

The latest iteration of AAMC's projection model accounting for NPs and PAs, even at unrealistically low ratios, demonstrates their large potential event on dr. shortage estimates. For instance, Exhibit 1 in the 2019 report indicates that, once NPs and PAs are factored in, the supply and demand projection lines for physicians converge most 2030, indicating that supply will meet demand. For the main intendance projections that factor in NPs and PAs as substituting for 1-half of a dr., the written report's third exhibit shows the physician supply and need lines converging in 2024. If projections used more realistic commutation ratios for NPs and PAs, the much-publicized future shortfalls of physicians would compress dramatically or perhaps fifty-fifty disappear. Wellness workforce planning should exist based on the all-time show available in order to avoid either shortfalls or surpluses—both acquit high costs to club.

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2. Jacobs F. US wellness care's biggest trouble: a doctor shortage. www.salon.com/2018/09/23/u-s-wellness-cares-biggest-problem-a-doctor-shortage. Accessed July 1, 2019.

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4. Cooper RA, Getzen TE, McKee HJ, Laud P. Economical and demographic trends indicate an impending dr. shortage. Health Aff (Millwood). 2002;21(1):140–154.

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5. US Government Accountability Office. Physician workforce: HHS needs better information to comprehensively evaluate graduate medical instruction funding. GAO-18-240. www.gao.gov/assets/700/690581.pdf. Accessed July 1, 2019.

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fourteen. Morgan P, Abbott D, McNeill R, Fisher D. Characteristics of main care part visits to nurse practitioners, physician assistants, and physicians in United States Veterans Health Administration facilities, 2006-2010: a retrospective cantankerous-sectional analysis. https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-10-42. Accessed July 17, 2019.

xv. Morgan P, Everett C, Hing E. Nurse practitioners, doctor administration, and physicians in community health centers, 2006-2010. Healthc (Amst). 2015;three(two):102–107.

16. Stange K. How does provider supply and regulation influence health intendance markets? Evidence from nurse practitioners and physician assistants. J Health Econ. 2014;33:one–27.

17. Morgan P, Everett CM, Smith VA, et al. Factors associated with having a physician, nurse practitioner, or physician assistant as primary care provider for veterans with diabetes mellitus. Research. 2017;54:46958017712762.

xviii. Virani SS, Akeroyd JM, Ramsey DJ, et al. Comparative effectiveness of outpatient cardiovascular disease and diabetes intendance delivery between advanced practice providers and dr. providers in master care: implications for care nether the Affordable Care Act. Am Center J. 2016;181:74–82.

xix. Virani SS, Akeroyd JM, Ramsey DJ, et al. Health care resource utilization for outpatient cardiovascular disease and diabetes intendance delivery among advanced practice providers and physician providers in chief care. Popul Health Manag. 2018;21(3):209–216.

20. Jackson GL, Smith VA, Edelman D, et al. Intermediate diabetes outcomes in patients managed by physicians, nurse practitioners, or physician administration: a accomplice study. Ann Intern Med. 2018;169(12):825–835.

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21. Larson EH, Hart LG, Ballweg R. National estimates of physician assistant productivity. J Allied Health. 2001;30(iii):146–152.

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22. Morgan P, Everett CM, Hing E. Fourth dimension spent with patients past physicians, nurse practitioners, and physician administration in customs health centers, 2006-2010. Healthc (Amst). 2014;2(4):232–237.

23. Negotiated Rulemaking Committee on the Designation of Medically Underserved Populations and Health Professional Shortage Areas. Negotiated Rulemaking Committee on the Designation of Medically Underserved Populations and Health Professional Shortage Areas Report: Appendices and Addenda. www.hrsa.gov/advisorycommittees/shortage/nrmcfinalreport.pdf. Accessed July 1, 2019.

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24. Doescher MP, Andrilla CH, Skillman SM, et al. The contribution of physicians, physician assistants, and nurse practitioners toward rural principal care: findings from a 13-state survey. Med Care. 2014;52(vi):549–556.

25. Essary AC, Greenish EP, Gans DN. Bounty and production in family medicine past practice ownership. Wellness Services Research and Managerial Epidemiology. http://hme.sagepub.com/content/3/2333392815624111.total.pdf+html. Accessed July ane, 2019.

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26. Quella A, Brock DM, Hooker R. Physician banana wages and employment, 2000-2025. JAAPA. 2015;28(vi):56–63.

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Keywords:

medico assistant; NP; healthcare workforce; physician; shortage; projections

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