Demographic and Health Workforce Trends: Implications for Cancer Care in the Future
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1 Demographic and Health Workforce Trends: Implications for Cancer Care in the Future Edward Salsberg Senior Director Center for Workforce Studies National Cancer Policy Forum Washington DC October 20, 2008
2 Presentation Overview Rising Need for Health Services Overview of the Health Workforce Physician Workforce Shortages The Oncology Workforce The Growing Need for Oncology Services Some Possible Strategies to Assure Access
3 Rising Demand and Need for Health Services
4 Drivers of Future Demand for Health Services Population growth US Pop Growing by 25 million/decade
5 Drivers of Future Demand for Health Services Population growth US Pop Growing by 25 million/decade Aging of the population Over 65 will double Major illness/chronic illness far more prevalent among the elderly Over 65 make twice as many physician visits as under 65
6 Average Visits to Physicians by People Over Age 45 Have Risen Significantly Over the Past 15 Years Under and Older Source: 1990, 2000, and 2005 NAMCS
7 Recent IOM Report Highlights Chronic Disease Needs of the Elderly Prevalence of Chronic Disease Hypertension Chronic Joint Systems Heart Disease Any Cancer Diabetes Stroke Chronic Bronchitis Overall Health Status Self-assessed health status as fair or poor Source: Retooling for an Aging America: Building the Health Care Workforce (IOM)
8 Drivers of Future Demand for Health Services Population growth US Pop Growing by 25 million/decade Aging of the population Over 65 will double Major illness/chronic illness far more prevalent among the elderly Over 65 make twice as many physician visits as under 65 Life style factors Rates of obesity, diabetes, etc. rising rapidly
9 Drivers of Future Demand for Health Services Population growth US Pop Growing by 25 million/decade Aging of the population Over 65 will double Major illness/chronic illness far more prevalent among the elderly Over 65 make twice as many physician visits as under 65 Life style factors Rates of obesity, diabetes, etc. rising rapidly Medical advances
10 Medical Advances are Likely to Lead to Increased Demand and Use of Services Medical innovations will result in better health and longer life, but they will likely increase, not decrease, Medicare spending. Eliminating any one disease will not save Medicare money. Obesity may be an important exception to the rule. Research Highlights: Future Health and Medical Care Spending of the Elderly; Rand 2005
11 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2006 (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
12 Drivers of Future Demand for Health Services Population growth US Pop Growing by 25 million/decade Aging of the population Over 65 will double Major illness/chronic illness far more prevalent among the elderly Over 65 make twice as many physician visits as under 65 Life style factors Rates of obesity, diabetes, etc. rising rapidly Medical advances Economic growth of the nation Public expectations Baby boom generation: high resources and expectations
13 Overview of the Health Workforce
14 The U.S. Health Workforce 2006: 17.6 Million and Growing Health Care Settings 13.1 Million Health Professions and Occupations 13.6 Million 4.0 million other jobs 9.1 million health professions jobs 4.5 million health professions jobs Source: Health Care Employment Projections: An Analysis of Bureau of Labor Statistics Occupational Projections, Center for Health Workforce Studies, University at Albany
15 Physicians Represent a Decreasing Share of the Health Workforce 4,000 Health Employment per 100,000 of Population. 3,500 3,000 2,500 2,000 1,500 1, Managers Technicians Therapists Aides LPNs RNs Pharmacists Dentists NPCs Physicians Adapted from Kendix and Getzen and the Bureau of Labor Statistics, Source: Richard Cooper
16 Optometrists Nurse Anesthetists Podiatrists Specialty NPs & PAs PHYSICIANS Clinical Nurse Specialists Psychologists Clin. Social Workers Psychiatric Nurses Counselors Therapists Pharmacists Primary Care Nurse Practitioners Nurse-Midwives Physician Assistants Acupuncturists Naturopaths Chiropractors Source: Richard Cooper
17 Job Growth in the Health Sector Compared to All Other Employment Sectors and Projected % 20% 15% 10% 5% 0% Health Care Employment Other Sectors Source: Health Care Employment Projections: An Analysis of Bureau of Labor Statistics Occupational Projections, The Center for Health Workforce Studies, University at Albany
18 Between 2006 and The fastest growth in the health sector is projected for home health care. Hospital employment is projected to grown at a much slower rate. Nearly 5.5 million health workers will be needed ro fill new jobs and to replace workers who leave their jobs across all employment sectors More than half of the top 30 occupations projected to grow the fastest in the U.S. are health occupations. Source: Health Care Employment Projections: An Analysis of Bureau of Labor Statistics Occupational Projections, The Center for Health Workforce Studies, University at Albany
19 Selected Health Occupations With the Largest Projected Need between 2006 and In Thousands of Jobs Registered Nurses Personal & Home Care Aids Home Health Aids 264 Nurses, Aids, Orderlies & Attendants Licensed Practical Nurses Physicians & Surgeons Medical Assistants Pharmacy Technicians New Jobs Replacements Source: Health Care Employment Projections: An Analysis of Bureau of Labor Statistics Occupational Projections, The Center for Health Workforce Studies, University at Albany
20 The Education/Training Supply Pipeline Can be Very Long; This is Particularly True in Medicine 3 to 5 years to add med education capacity 4 years of medical school 3 to 7 years of training Total: 10 to 16 years before a small marginal increase in numbers of US graduates
21 Physician Workforce Shortages
22 Recent Reports of Physician Shortages: Specialty Studies Allergy & Immunology (2000) Anesthesia (2003) Cardiology (2004) Child Psychiatry (2006) Critical Care Workforce (2006) Dermatology (2004) Emergency Medicine (2006) Endocrinology (2003) Family Medicine (2006) Geriatric Medicine (2008) General Surgery (2007) Medical Genetics (2004) Neurosurgery (2005) Oncology (2007) Pediatric Subspecialty (2008) Primary care (2008) Psychiatry (2003) Public Health (2007) Rheumatology (2007)
23 Recent Reports of Physician Shortages: State Reports Alaska (2006) Arizona (2005) California (2004) Florida (2005) Georgia (2006) Hawaii (2008) Idaho (2007) Iowa (2007) Kentucky (2005) Maryland (2008) Massachusetts (2007) Michigan (2005) Mississippi (2003) Nevada (2006) New York (regional) (2007) New Mexico (2007) North Carolina (2007) Oregon (2004) Texas (2002) Utah (2006) Virginia (2007) Wisconsin (2004)
24 Key Factors Influencing Future Supply Medical and osteopathic enrollment International migration and IMG policies GME positions Aging of physician workforce & retirement Gender and generational differences/lifestyle choices of physicians Productivity and organizational changes
25 First Year MD and DO Enrollment in 2012 is Likely to be more than 5,500 (28%) Higher than in # and % Increase MD 16,488 19,909 3, % DO 3,079 5,227+ 2, % Combined 19,567 25,136 5,569 28% Source: 2007 AAMC Dean s Enrollment Survey 2007 AACOM Enrollment Survey
26 GME Growth : Residents and Fellows in ACGME Accredited Training Programs 120, ,000 80,000 81,410 89,368 98,143 98, ,012 60,000 40,000 20, * *Data for 1987 excludes residents in combined specialty programs. Source: JAMA Medical Education issues
27 Baseline Physician FTE Supply and Demand Projections, , , ,000 Baseline Demand 796, , ,400 FTE Physicians (excl. residents) 750, , , , , , ,900 Baseline Supply 650, ,
28 Projected FTE Physicians, Baseline & Most Plausible Scenarios, , ,000 FTE Physicians (excl residents) 850, , , ,000 Most Plausible Demand Baseline Demand Most Plausible Supply Baseline Supply 159, , ,
29 Even with an Expansion of Training Positions, Demand will Exceed Supply 900, ,000 FTE Physicians (excl. residents) 800, ,000 Shortfall Additional Supply from GME Expansion 700,000 Baseline Supply 650, Year
30 Slow GME Growth: Will Growth Continue? 1997 BBA caps number of residency positions Medicare will cover The total number of residents in ACGME flat from 1997 to 2002 but has increased 7.9% over the past 5 years Unknown how much if at all - residency programs will continue to grow in the coming years. Federal funding cuts for GME would likely reduce growth The general fiscal health of hospitals may determine whether growth continues in the absence of new federal support for GME Without GME growth, US MDs and DOs are likely to displace IMGs and physicians per capita will peak about 2015
31 Sub-Specialization is Increasing Across a Wide Range of Specialties Specialty Anesthesiology Dermatology Family medicine Internal medicine* Neurology Orthopaedic surgery Pathology Pediatrics Psychiatry Radiology * Internal medicine excludes the sub-sub-specialties of clinical cardiac electrophysiology and interventional cardiology. Source: JAMA September 10, 2008 Percent of Residents Completing Program Who Sub-Specialize AY AY
32 Oncology Workforce
33 Percent Seeing an Oncologist Varies by Site and Stage (Percent with at least one oncology visit within first 12 months of diagnosis) Prostate Breast Colorectal Lung N = 18,258 11,698 9,528 5,002 In Situ 0% 56% 12% 57% Stage I 12% 76% 35% 48% Stage II 12% 83% 62% 70% State III 14% 85% 83% 76% Stage IV 31% 92% 80% 79% Unstaged 11% 64% 41% 51% Source: NCI, May 2006
34 Physician Specialties Involved in Cancer Care Dermatologists Gastroenterologists General Surgeons Surgical specialists Colorectal surgery Otolaryngology Neurosurgery Plastic surgery Urology Gynecologists Hematologists Medical oncologists Oncologists Palliative care Pathologists Primary care physicians?? Pulmonologists Radiation oncologists Radiologists Surgical oncologists
35 And a Large Team Other Health Workers Care management team Oncology Nurse Specialist Physician assistant Registered Nurses Radiation and lab techs Clinical pharmacists Infusion technicians Dieticians Cancer Care Coordinator Social worker/counselors Psychologists Spiritual counselors Hospice workers Researchers Financial counselors Genetic Counselors Occupational therapists Physical therapists Respiratory therapists Speech therapists Aides and assistants
36 The Need and Demand for Oncology Services
37 Oncology Visits Projected to increase by 50% from 2005 to 2020 Number of cancer patients in the U.S. is projected to increase from 11.5 million in 2005 to 18.2 million in 2020 (55% increase) Oncology visits are projected to increase from 38 million in 2005 to 57 million in 2020 Increase in services due to an increase in survivorship and the aging of the population Source: Warren, J.L., Mariotto, A.B., Meekins, A., Topor, M., and Brown, M.L. (2008) Current and Future Utilization of Services from Medical Oncologists. Journal of Clinical Oncology 26 (19):
38 Age-Specific Cancer Incidence Rates/100,000, ,500 3, ,500 2,000 1,500 1,000 Male Female < Age Group Source: CDC, Age-Specific Invasive Cancer Incidence Rates by Primary Site and Race, United Sates (U.S. Cancer Statistics, 2000). Prepared by AAMC Center for Workforce Studies
39 Possible Solutions
40 Oncologists Views on Addressing Shortages (Results of 2006 Practitioner Survey) Increase Efficiency Increase / extend oncology workforce Increase use of related care providers Reduction of paperwork and regulations Improved IT such as electronic medical records Increased use of NPs/PAs Train more clinical oncologists Increased use of oncology nurses and CNS Create incentives to delay retirement Hospice and palliative care providers Social workers, counselors and patient educators Hospitalists Pain and symptom management specialists Primary care providers to care for patients in remission % Significant Potential 61% 43% 36% 34% 32% 28% 26% 24% 20% 17% 15%
41 Some Potential Strategies to Help Assure Access to Cancer Care in the Future Increase oncology training positions Increase inter-disciplinary education and team practice (especially for non-physician clinicians) Expanded use of non-physician health professionals (Scope of practice/numbers/systems of Care/Reimbursement) Redesign service delivery/improve efficiency and effectiveness Involve and empower patients and their families Respond to needs of younger and older physicians, such as flexible scheduling and part time work
42 The Number of PAs Will Continue to Grow Rapidly as the Number of New PAs Entering Practice Each Year Has Grown 5 Fold in the Past 15 Years Number of newly certified PAs by Year 4,814 (2007) (1987) 1,387 (1993) Year Source: National Commission on Certification of Physician Assistants, April 2008
43 The Number of New Advanced Practice Nurses is Also Growing Rapidly But Uncertain Impact of Increasing Educational Requirements , Total APNs ,397 NPs Source: American Association of Colleges of Nursing Total APN includes: NP, CNS, Combined NP/CNS, Nurse Midwifery, Nurse Anesthesia, and Post-Master s NP
44 Some Potential Strategies to Help Assure Access to Cancer Care in the Future Delivery system redesign to improve efficiency and effectiveness Expanded use of non-physicians Expanded use of teams Expanded use of primary care physicians Support demonstrations and evaluation Improve IT + EMR Payment System Reform Promote evidence based medicine Make wiser use of our limited supply of physicians
45
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