Transcript 7th AAMC MD Workforc

Adam Smith’s Invisible
Handshake With Hippocrates
D. Douglas Miller, MD, CM, MBA
AAMC Robert G. Petersdorf Scholar
AAMC Petersdorf Project
Premise 1
National and regional economies directly
and indirectly affect medical student
career decisions.
Corollary 1
Significant economic downturns (i.e.
recessions) create financial pressures that
impair the physician workforce’s free
market capacity to self-correct.
AAMC Petersdorf Project
Premise 2
Resourcing of state/provincial health care
costs is critical to public medical education
expansion & workforce balance.
Corollary 2
Public resource contraction impacts
household finances, and medical student
‘consumer ’decisions tied to tuition price,
personal debt & future income.
AAMC Petersdorf Project
Premise 3
Publicly-financed national health care
systems in which medical students clinically
train affect their ultimate career decisions.
Corollary 3
Different U.S. and Canadian health care
delivery systems create different primary care
workforces.
The 1929 Depression & >15 Recessions
“The Great Recession”– Economic Ground Zero
The “Great Recession” of 2007-09
Impact Across the 49th Parallel
United States
Canada
GDP Nadir
-6.8%
-1.8%
Stock Market Fall
-52%
-48%
Unemployment
10.1%
8.3%
CCI Nadir
25
54
Savings Rate
8%
1%
USA Breaking From the Pack
USA
Canada
I. U.S. and Canadian Economies
(1980-2010)
 For ~30 years, both national economies grew & diversified
to comparable degrees.
 After recessions, health care cost escalated transiently
then plateau’d; post-2000 increases as % of GDP were
comparable (U.S.=+27.2%, Canada=+28.5%).
 2007-09 “Great Recession” had a more severe impact on
the U.S. economy, although ARRA permitted more U.S.
personal savings and financial deleveraging.
 2000-01 “Dot.com” recession did not impact Canadian
CCI. 2007-09 recession reduced Canadian personal
savings rates to all time lows.
National Health Care Policy Actions (1980-2010)
TWO PATHWAYS TO
  UNIVERSALITY
• >10 U.S. federal health care
policies (MCR Secondary
Payer Act, MCR PPS, COBRA,
EMTALA, MCR Catastrophic
Coverage Act, MCR RBRVS,
HIPAA, BBA, SCHIP, MCR Rx
Drug Act, PSQIA, ARRA,
CHIPRA, ACA)
• 1 Canadian federal health
care policy (CHA), renewed
by 2003 Ministers’ Health
Care Accord
1.6
1.4
1.2
1
C
H
A
A
C
A
0.8
USA
Canada
0.6
0.4
0.2
0
Recessions
II. U.S. and Canadian Health Policy
(1980-2010)
 >10-fold more U.S. federal health care policies enacted to




address costs/gaps/access before 2010 ACA ‘universality’.
2003 Canadian policy renewal of 1984 single-payer public
insurance and federal funding commitments.
U.S. private sector co-insurance options and health
insurance premiums grew incrementally from 1995-2003,
achieving a ‘balanced’ market circa 2005.
Both countries face regional health & wealth disparities,
but the U.S. has greater health care cost variability.
U.S. policy stakeholders & care delivery agents add
complexity, threatening ACA implementation & system
sustainability.
2010
2009
2008
2007
2006
2005
2004
2003
1978-1992
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
0.5
1984
1983
1982
1981
1980
1979
1978
U.S. GQ Primary Care Choices
(1978-2010)
0.6
1998-2010
0.4
?
FM
0.3
IM
Peds
0.2
Total PC
0.1
0
Primary Care Career Choices
U.S. GQ (2001-2010)
Canada CGQ (2001-2010)
0.6
0.35
0.3
0.5
0.25
0.4
FM
FM
0.2
IM
0.15
IM
0.3
Peds
Peds
PC Total
PC Total
0.2
0.1
0.1
0.05
0
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
2001 2002 2003 2004 2005 20062007 20082009 2010
III. Graduate Profiles & Primary
Care Career Choices (2001-2010)
U.S. GQ
Canada CGQ
 Female = +2.7%; av. debt = +38%
 Female = +4.7%; av. debt = +32%
 After steady PC choice decline,
 After stable PC choices, sudden
sudden 2008-10 increase, mainly
from internal medicine (IM)
 Abrupt PC increases preceded

both Dem. pro-universality policy
reform efforts (Clinton 1990-93,
Obama 2008-10); IM choices may
reflect (mal-) adaptation to policy
outcome uncertainties.
2009-10 increase, mainly from
family medicine (FM)
Delayed (from 2003 policy renewal)
2009 FM increase tracked regional
policy actions (i.e., a new North
Ontario medical school, PC ‘teams’,
better PC pay, etc.), and vested
universal access to care role of FM.
1978
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
U.S. v MA GQ Primary Care Choices
0.7
0.6
0.5
0.4
Mass. PC Total
0.3
USA PC Total
0.2
0.1
0
MA Primary Care Career Choices
% Annual Variability
% PC Change Histogram
1.2
9
1
8
0.8
7
0.6
6
0.4
5
% GDP Change
More
0.3
0.2
0.1
0.09
0.08
0.07
12
0.06
0
0.05
-0.6
0.045
1
0.04
-0.4
0.035
2
0.03
-0.2
0.025
3
0.02
0
0.015
4
0.01
% PC Change
0.005
0.2
-0.8
Kurtosis = 7.5
Skewness = 2
IV. MA Policy Reform & MD Career Choice
 Phase 1 (2005-07) & Phase 2 (2008-2010) MA health care
policy reform increased the insured population (%, #).
 MA PC choices paralleled the U.S. trend of sharp 2005-07
declines, and abrupt 2008-10 increases.
 After 2005, annual variability in PC choices was greater in
MA v U.S. (43±35% v 22±28%; p<0.005), with year-to-year
variability ≥20% in 5/6 years in MA.
 Dual pressures of state and national policy reforms may
contribute to greater PC choice volatility, and lower GQ
satisfaction with non-clinical educational domains in MA.
0.14
Unemployment
0.12
140
0.1
0.06
USA
0.02
0
1997-1
1998-3
2000-1
2001-3
2002-5
2002-11
2003-5
2003-11
2004-5
2004-11
2005-5
2005-11
2006-5
2006-11
2007-5
2007-11
2008-5
2008-11
2009-5
2009-11
2010-5
2009
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
Fiscal Year
Lagging & Leading Economic Indicators
160
Consumer Confidence Index
120
100
0.08
80
Canada
US CCI
60
Cdn. CCI
0.04
40
20
0
V. Career Choice Confidence
 Occupational Alternatives Questionnaire (OAQ):
 fell significantly in the 2009-10 NRMP match cycle; greater
M declines were sustained into the 2010-11 cycle.
 OAQ trended with lagging economic indicators (i.e.,
unemployment) > leading economic indicators (i.e., CCI)
U.S. Graduate Career Choice Confidence
OAQ v CCI Trends
Gender OAQ Differences
3.5
3.20
3
3.00
2.5
2.80
2
US MS OAQ
1.5
F
2.60
US CCI x0.025
1
M
2.40
0.5
2.20
2007-1
2007-4
2007-7
2007-10
2008-1
2008-4
2008-7
2008-10
2009-1
2009-4
2009-7
2009-10
2010-1
2010-4
2010-7
2010-10
2011-1
0
2.00
2007
2008
2009
2010
2011
V. Career Choice Confidence
 19% of 2010-11 graduates answered “YES” to:
“Did factors affecting the U.S. economy influence your
specialty decision?”
 “YES” respondents cited:
 emotions (i.e., fear, pessimism, uncertainty, insecurity)
 mental accounting for future income (i.e., salary,
reimbursement, debt repayment capacity).
Top 10 Themes for “Yes” Responses:
Code Counts
Yes respondents No respondents
N = 564
N= 1,314
salary
14% (77)
8% (99)
loan repayments
9% (49)
2% (28)
debt consideration
8% (46)
5% (73)
economy as a general
consideration
6% (34)
1% (14)
loan size
5% (31)
<1% (5)
future reimbursement
5% (28)
2% (32)
negative perceptions of
primary care
5% (26)
<1% (3)
health care reform
4% (24)
<1% (12)
decided against lower
paying specialties
4% (21)
< 1% (3)
supply and demand
4% (20)
< 1% (4)
Top 10 Themes for “No” Responses:
Code Counts
No respondents
N = 1,314
Yes respondents
N = 564
happiness/enjoyment
15% (191)
1% (6)
chosen specialty
interest
10% (137)
3% (17)
passion
9% (119)
1% (6)
salary
8% (99)
14% (77)
money not important
8% (99)
0% (0)
debt consideration
5% (73)
8% (46)
chose primary care
5% (64)
2% (9)
stability of medicine
4% (51)
2% (10)
good living
3% (35)
<1% (5)
future reimbursement
2% (32)
5% (28)
confirmation
2% (32)
<1% (2)
long-term view
2% (32)
< 1% (2)
Medical Applicant Price Sensitivity
Total Applications
Average Tuition & Fees
30000
50000.00
45000.00
25000
40000.00
35000.00
20000
U.S. WOMEN
U.S. MEN
15000
30000.00
Canada
25000.00
U.S. Private
Canada WOMEN
Canada MEN
10000
U.S. Public
20000.00
15000.00
10000.00
5000
5000.00
0
0.00
1996 1998 2000 2002 2004 2006 2008 2010
9697989900 01 0203040506070809 10
Medical Applicant Price Sensitivity
Canadian Price Elasticity
U.S. Price Elasticity
3.00
2
1
2.00
1.00
-1
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
US Women Private
US Women Public
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0.00
-1.00
US Men Private
-2
-3
US Men Public
-4
-5
-2.00
-6
-3.00
-7
Canada Women
Canada Men
Conclusions
1. In a severe economic recession, free market career choice
tilts the physician workforce balance (i.e., PC versus
specialists, and choices within PC).
2. Without government regulation &/or professional
organization intervention, ‘bad economy’ career decisions
reflect personal finances > public interests.
3. Health care policy fostering universal PC access &/or
rewarding accountable care alters MS-4 career decisions:
- in favor of perceived system needs (for FM in Canada),
- in reaction to systemic uncertainties (to IM in U.S., MA).
Conclusions (cont’d.)
4. 19% of 2010-11 graduates cited economic factors
affecting their specialty decisions, with M>F career
choice confidence erosion since 2009-10.
5. Medical school applicant elasticity to higher tuition:
- ‘bearish’ demand occurred in U.S. & Canadian
men from 2000-2002
- ‘bullish’ applicant supply occurred in Canada &
the U.S. from 2007-09.
Thanks to all my EDI, AAMC and AFMC colleagues