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MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
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OA/ID Number:
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FoIderlD:
Folder Title:
Workforce Briefing Book [1]
Stack:
Row:
Section:
Shelf:
Position:
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�WORKFORCE
Workgroup 12
BRIEFING BOOK
�FOR SOCIAL USE ONLY
''0\ r;s.-r
I. Issues
A.
Lack of a Coherent H^tionaf Msjatifc''WerMv^. Pftifey
B.
Effect of Nationaf I&Sfih -Reform on Workfordb' Issues^
:
II. Recommendations ard Rationale
A. Summary of Workgroup Proposal
B. National Health Care Workforce Policy
'/ ^ - i
C. Physician and Non-Physician Primary and Spepiaity ^c.^ywders
D. Basic Nursing and Allied Health Occupations
- .-j
,J
E. Workforce for Underserved Rural ana Urban Areas
F. Workforce Diversity
"
v
••-*'^i?cin%
'•
1
"
i
G. National Service Initiative: "Service for a HeaUiiy Amcjrica"
HI. Questions and Answers
IV. Political Considerations
A. Providers
1. Nurses and Physician Assistants
2. Allied Health Professionals
3. Physicians
B. Academic Institutions
1. Teaching Hospitals and Medical Schools
2. Nursing Schools
i ^
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V. Appendix
Tab 1 Council on Graduate Medical Education
Council on Graduate Medical Education (COGME) Third Report: Improving
Access to Health Care Through Physician Workforce Reform. Health
Resources and Service Administration (October 1992).
Tab 2: Josiah Macy, Jr, Foundation
Report of the Josiah Macy, Jr. Foundation (July 1992).
Taking Charge of Graduate Medical Education: To Meet the Nation's Needs in
the 21st Century. Proceedings of a Conference. Josiah Macy, Jr. Foundation
(1992).
Tab 3: Pew Health Professions Commission
Primary Care Workforce 2000 — Federal Health Policy Strategies. Pew
Health Professions Commission (March 1993).
Tab 4: Physician Supply and Distribution
Mullan F, Rivo M, and Politzer R. Doctors, Dollars and Determination:
Making Physician Work-Force Policy. Health Affairs Supplement 1993: 138151.
Budetti PP. Achieving a Uniform Federal Primary Care Policy - Opportunities
Presented by National Health Refonn. Joumai of the American Medical
Association 1993: 269; 498-510.
Zuvekas A, Cawley JF and Budetti PP. Increasing the Availability of
Community-Based Primary Care Practitioners. The George Washington
University, Center for Health Policy Research (Draft, April 1993).
Tab 5: Physician Supply and Distribution (continued^
Schroeder SA. The Making of a Medical Generalist. Health Affairs Summer
1985: 22-46.
Sheldon GF. Graduate Medical Education: Issues for the 21st Century. 161
The American Joumai of Surgery 1991: 161; 294-299.
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Weiner JP. The Effects of Future Health Care System Trends on the Demand
for Physician Services: An Assessment for Selected Specialties. The Johns
Hopkins University (Issue paper prepared for the Council on Graduate Medical
Education, September 13, 1991).
Tab 6: Regulation of Advanced Practice Nursing
Safriet B. Health Care Dollars and Regulatory Sense: The Role of Advanced
Practice Nursing. Yale Joumai on Regulation 1992: 9; 149-220.
Tab 7: Advanced Practice Nurses and Physician Assistants
Emelio J et al. PA's, NP's, and CNM's: An Overview by the Bureau of Health
Professions. (Draft, March 1993).
Pearson L. 1992-93 Update: How Each State Stands on Legislative Issues
Affecting Advanced Nursing Practice. The Nurse Practitioner. The American
Joumai of Primary Health Care. 1993: 18; 23-38.
Health Technology Case Study 37 — Nurse Practitioners, Physician Assistants,
and Certified Nurse-Midwives: A Policy Analysis. Office of Technology
Assessment (December 1986).
Tab 8: Allied Health Professionals
Bernstein S et al. Health Personnel in the United States, Eighth Report to
Congress 1991: Allied Health. Bureau of Health Professions (September 1992)
(excerpts).
Allied Health Services: Avoiding Crisis. Institute of Medicine, Nat'l Academy
of Sciences 1989.
Chapter 5: The Role of Educational Policy in Influencing Supply.
Chapter 7: Licensure and Other Mechanisms for Regulating Allied Health
Personnel.
Clare DR et al. Health Professions Education For The Future: Schools in
Service to the Nation. Report of the Pew Health Professions Commission
February 1993: 33-45.
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Tab 9: Physicians and the Underserved
Politzer RM et al. Primary Care Physician Supply and the Medically
Underserved. Joumai of the American Medical Association 1991: 266; 104109.
Tab 10: Rural Health Workforce
Rural Health Personnel Issues and Options. Health Care in Rural America 17.
Office of Technology Assessment (September 1990).
Hanson C. Access to Rural Health Care: Barriers to Practice for NonPhysician Providers. Bureau of Health Professions (November 1992).
Van Hook R et al. Study of Models to Meet Rural Health Care Needs
Through Mobilization of Health Professions Education and Services Resources.
Bureau of Health Professions (June 1992).
Tab 11: Area Health Education Centers (AHECs)
Area Health Education Center of South Texas. The University of Texas Health
Science Center at San Antonio. (Annual Report, 1992)
Area Health Education Center of South Texas. The University of Texas Health
Science Center of San Antonio, (pamphlet).
Tab 12: Health of the Public Program
Health of the Public: The Academic Response. Joumai of the American
Medical Association 1992: 276; 2497-2502.
Academic Health Centers and the Community: A Practical Guide for Creating
Shared Visions. Health of the Public (September 1992).
Tab 13: Kellogg Foundation Community-Based Public Health Initiative
Seven State Consortia Selected to Become Community-Based Public Health
Models. W.K. Kellogg Foundation (August 1992)
Community-Based Public Health. CBPH News W.K. Kellogg Foundation
(October 1992).
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Tab 14: Workforce Diversity
Spratley E. Minority Employment in the Health Fields Health Personnel in
the United States, Eighth Report to Congress. Bureau of Health Professions
(September 1992).
Tab 15: Letters from Professional Organizations
�FOR OFFICIAL USE ONLY
DEVELOPING A WORKFORCE FOR THE NEW HEALTH CARE SYSTEM
I. ISSUES
SUMMARY OF ISSUES
A.
Lack of a Coherent National HeaUh Workforce Policy
The current training system does not properly prepare practitioners.
There is a maldistribution of physician specialties.
Advanced practice nurses and physician assistants are underutilized.
There is inadequate public support for basic nurses and allied health
professionals.
There are not enough health care providers in rural areas and inner cities.
The health care workforce is not racially, ethnically and culturally
representative of the people it serves.
B.
Effect of National Health Refonn on Workforce Issues
•
Reversing fee-for-service incentives should make primary care more attractive.
•
Universal access to health care will increase the need for primary care
physicians.
•
Reducing fee-for-service payment of academic health centers may reduce
incentives to train specialists.
•
There may be a need for stricter regulation of training if current payment
practices continue.
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A.
LACK OF A COHERENT NATIONAL HEALTH WORKFORCE POLICY
•
Beginning in 1960, a series of explicit federal policies led to a dramatic
increase in funding for the construction of medical schools, support of students
and faculty, andfinancing(through Medicare) of an unlimited number of
residency training positions.
•
Current federal funding for graduate medical education pays all teaching
hospitals with accredited programs a set amount per resident with
minimal regard to location, specialty or eventual practice.
1
•
•
In 1994, the government will also pay approximately $4 billion as an indirect
medical education adjustment (IMEA) to compensate teaching hospitals for
their higher patient care costs. Payments are made based on the resident-tobed ratio, which is viewed as a proxy for severity of illness as well as
compensating for higher utilization of services by trainees. (See briefing book
for Academic Health Center Workgroup)
•
1.
In 1994, the federal government will pay $1.6 billion in direct graduate
medical education (GME) funding, or 30% of estimated training costs
(because approximately 30% of patients are Medicare recipients). Direct
funding pays residents' stipends and some teaching costs.
In response to these incentives, which equal $18,000 in direct and $52,000 in
indirect reimbursement per resident, teaching hospitals increased the
number of residents from 82,000 in 1980 to 97,000 in 1993, the majority in
specialty fields.
The current training system does not properly prepare practitioners.
a.
b.
1
Changes in education are essential long-term interventions because life-long
practice habits and organizational behavior are instilled during training.
Given current practice trends and open-ended federal funding, the educational
process has been controlled mainly by specialty departments emphasizing
high-technology, acute hospital care. This phenomenon is intimately related
to the rise in national health care costs.
Teaching hospitals are acute care hospitals with residency training programs.
Currently, only acute care hospitals are eligible to receive federal funds for resident
training.
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c.
2.
Education focused on caring for hospitalized patients requiring intensive
management of acute disease is unlikely to produce a health care workforce
with an appropriate geographic distribution, public health competency, pattern
of clinical practice, interdisciplinary cooperation, diversity, and mix of primary
and specialty care providers.
There is a maldistribution of physician specialties.
im
Physicians
MDs/100,000 population
Percentage of generalists
268,000
146
53
im
588,000
233
33
(COGME Report — see Tab 1)
a.
b.
Less than one in three physicians in the United States currently practices
as a generalist, compared to 50-70% in other industrialized countries.
c.
Health care reform designed to assure universal access to health services
delivered by integrated health plans will require significantly more primary
care physicians. Community-based, prevention-oriented services rely
principally on primary care providers.
d.
3.
The United States has too many medical and surgical subspecialists and not
enough primary care physicians (family physicians, general internists and
general pediatricians).
The Medical Outcomes Study demonstrated that physicians trained as
specialists display more costly practice patterns than those trained as
generalists when treating similar problems.
Advanced practice nurses and physician assistaats are upderutilized.
a.
Advanced practice nurses — nurse practitioners, certified nurse midwives,
certified registered nurse anesthetists, and clinical nurse specialists — are
trained to provide primary care and other medical services. It costs about
$200,000 to train a family physician, but only about $20,000 to train a
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nurse practitioner.
b.
Studies show that advanced practice nurses and physician assistants could
safely substitute for physicians for up to 90% of pediatric and 80% of
adult routine primary care.
c.
Nurse anesthetists administer more than 65% of all anesthetics and are the sole
providers of anesthesia in 85% of rural hospitals. International comparisons
suggest that at least 75% of prenatal care and deliveries could be safely
provided by midwives.
d.
According to the U.S. Office of Technology Assessment, advanced practice
nurses are "especially valuable in improving access to primary care and
supplementary care in rural areas and in health programs for the poor,
minorities, and people without health insurance" provide care "as good as or
better than care provided by physicians" and have "better communication,
counseling and interviewing skills than physicians."
e.
Nurses, physician assistants and allied health professionals face additional
barriers to practice that extend beyond the legitimate protection of the public
— more than 100,000 nurses have been trained for advanced practice but
only about half are providing those services.
2
•
•
2
State practice acts exist in a variety of political contexts, and
conflicts between professions, especially in a fee-for-service
environment, often give rise to expensive litigation that discourages
appropriate non-physician practice.
Institutional barriers result from traditional biases, usually favoring
physicians, and physicians' financial self-interest. For example,
although more than 50% of women choose midwives when available
in certain health maintenance organizations, midwives are excluded
from practice in most hospitals and many women have been forced to
choose between hospitals and midwives when they should be entitled to
both.
All states have laws, referred to as professional practice acts, that define the
qualifications and scopes of practice of doctors and nurses. Many states also have
practice acts that govern certain allied health professions.
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4.
There is inadequate public support for basic nurses and allied health
professionals.
3
a.
b.
Approximately 60 health professions are educated in well-developed programs
conducted in nationally accredited institutions of higher learning, meet licensure
and certification standards, and are in many cases regulated in their legal
scopes of practice by state practice acts.
c.
Because medical care is based disproportionately on acute illness, many
Americans lack proper preventive and public health services. Community
nurses and allied health professionals serve these needs.
d.
Although many health professionals will be in increasingly short supply,
educational institutions lack sufficient funding to substantially expand their
training programs, including money to produce and retain faculty.
e.
5.
There are 2,400,000 nurses and 775,000 allied health professionals in the
United States.
In addition, potential applicants often have limited personal financial
resources and studentfinancialaid isfrequentlyinadequate.
There are not enough health care providers in rural areas and inner cities.
a.
b.
3
Approximately 23% percent of Americans live in rural areas where which
the average physician-to-population ratio is 0.67 per 1000 (versus 2.40 per
1000 in the U.S. as a whole). Inner cities have similar shortages; in
Harlem, the ratio is 0.83 per 1000. These regions are classified as Health
Professional Shortage Areas (HPSAs). Non-physician providers are also
underrepresented in rural and urban HPSAs.
There are large inequities in the rural and inner city practice environments,
including payment differentials between geographic areas and between
physician and non-physician providers and a lack of infrastructure to support
"Allied health professionals" include clinical laboratory personnel, physical therapists
and physical therapy assistants, occupational therapists and occupational therapy
assistants, dietitians, medical record personnel, diagnostic imaging personnel, speech
language pathologists and audiologists, respiratory therapists, and several other types of
service providers.
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providers in practice and to reduce professional isolation and burnout.
c.
d.
6.
Lack of workforce diversity contributes to the shortage. Students from rural
areas are more likely to practice in rural areas and minority students are
more likely to serve minority populations.
The provider shortage is also related to the acute-care focus of current training.
Providers educated and trained in rural areas or inner cities will be more
likely to practice there. Providers trained in university and suburban
community hospitals usually stay there.
The health care workforce is not racially, ethnically and culturally representative
of the people it serves.
a.
Racial and ethnic minorities will comprise approximately 30% of the U.S.
population in 2000 and 40% in 2010. Effective strategies to reduce the
spiralling cost of health care must include a provider population that is
better able to prevent or effectively manage the diseases that afflict
minorities.
b.
The health care workforce, like the President's cabinet, should look like
America.
c.
While minorities constitute 22% of the population, they make up only seven
percent of physicians, ten percent of medical students and less than three
percent of medical school faculty.
d.
Minorities are underrepresented in other health professions — they constitute
only eight percent of physician assistants, eight percent of nurses, three percent
of allied health professionals and five percent of dentists.
e.
Despite significant scientific and technological advances, the health status of
racial and ethnic minorities remains poorer than that of the majority
population.
•
Life expectancy for the general population is 75 years; life expectancy
for African-Americans is only 69.4 years. Infant mortality rates for
African-Americans are 2.4 times higher than for Euro-Americans.
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•
•
f.
B.
One reason is that care is unavailable or access is extremely limited.
Minority health professionals are more likely to provide primary
care and to practice in underserved rural and inner city
communities.
African-Americans who obtain health services are less likely than
Euro-Americans to receive certain therapies. This reflects
institutional biases and reinforces the need for culturally attuned
providers. A 1985 HHS report suggested that the persistently small
number of health care providers from certain minority groups may
be a factor in the poorer health of racial and ethnic minorities.
Because of the large amounts of debt incurred by medical trainees,
economically disadvantaged young adults (who tend to be more racially diverse
and to come from medically underserved areas) may be less likely to go to
medical school.
EFFECT OF NATIONAL HEALTH REFORM ON WORKFORCE ISSUES
1.
The most important improvements in the character and distribution of the
health care workforce will result from changes in the overall health
system, not specific interventions with respect to training.
2.
Changes in training programs, especially for physicians, are long-term
interventions because only a small fraction of the health care workforce
graduates each year.
a.
3.
1.
If, starting in 1995, our medical education system produced 50% rather
than 15% primary care physicians (our current number), we would not
equalize the number of generalists and specialists in practice until 2030.
Career choices in the health professions are not determined by any one factor,
but are influenced by background, interests, access, training process, and
financial and non-financial opportunities.
Reversing fee-for-service incentives should make primary care more attractive.
a.
Removing the pressure to subspecialize inherent in a fee-for-service
payment system should improve relative compensation for primary care
providers and reduce the prevalence of specialists.
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b.
c.
2.
Because accountable health plans will bearfinancialrisk for
overutilization, they should restrain expensive patterns of specialty care,
although considerable fee-for-service practice willremainduring the
transition. Demand for generalist physicians has already increased in areas
with many capitated health plans.
In the short term, the RBRVS fee schedule (especially if it were extended to
all payers) will increase compensation for generalist physiciansrelativeto
specialists.
4
Universal access to health care will increase the need for primary care physicians.
a.
b.
3.
The currently underserved will require predominantly primary care
services.
Plans (and primary care providers) will receive adequate payment for
treating these patients.
Reducing fee-for-service payment of academic health centers may reduce
incentives to train specialists.
a.
Teaching hospitals, especially those that provide substantial charity care,
overuse residents because federal subsidies make them cheaper than hiring
staff physicians or non-physician health care workers.
b.
Specialty residents are favored by teaching hospitals because they assist highprofile faculty practice programs in technologically sophisticated areas that
have received substantial reimbursementfromfee-for-service payers. New
forms of reimbursing providers, including academic centers, should reduce the
demand for these services.
5
c.
If academic health centers decide to expand their specialty tracks to staff
4
Part B of Medicare has recently begun compensating physicians according to a
resource-based relative value scale (RBRVS) that is intended to improve payment for
"cognitive" (e.g. primary care) as opposed to "procedural" services.
5
Accountable health plans will contract with providers for services. Many contracts
will be "capitated" (per enrollee) or "bundled" (per package of services) rather than on a
piecework basis.
8
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"Centers of Excellence" that are adequately reimbursed through health plans,
care should be taken to ensure that federal training funds are not used to
subsidize staffing.
4.
There may be a need for stricter regulation of training if current payment
practices continue.
a.
If the broader goals of health reform are achieved — and the market for health
care training is brought into line with the market for practice by removing
perverse incentives — fewer long-term workforce-related interventions will be
needed.
b.
However, if current incentives (fee-for-service reimbursement and higher
compensation for the use of specialized technology) persist, an expanded
physician supply will not drive down costs or improve geographic distribution,
and the total number of physicians, or at least the number of specialists,
may need to be limited.
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n. RECOMMENDATIONS AND RATIONALE
SUMMARY OF WORKGROUP PROPOSAL
A.
National health care workforce policy
•
•
•
B.
Charter a commission to develop and implement a national policy.
Use an all-payer fund to continue public investment in workforce training.
Establish specific conditions for the receipt of public funds.
Physician and non-physician primary and specialty care providers
Fund advanced practice nurses and physician assistants as well as physicians.
Maintain or expand direct funding for graduate health education.
Move to a national limit of 50% primary care residency graduates.
Do WL limit total positions to a fixed percentage of medical school graduates.
Emphasize programs to retrain specialist physicians as generalists.
Modify professional practice acts to level the playing field for non-physicians.
Request antitrust and insurance commissioners to police anticompetitive
practices.
Reimburse non-physician providers under Medicare and Medicaid.
Put into place targeted federal programs to promote primary care.
C.
Basic nursing and allied health occupations
Encourage states to review and revise their professional practice acts.
Do not enact broad anti-discrimination legislation.
Fund targeted training programs for non-physician providers.
Restructure educational loan programs to include non-physician providers.
Develop programs for long-term care and mental health care providers.
D.
Workforce for underserved rural and urban areas
•
•
Encourage providers to enter practice in inner cities and rural areas.
Encourage providers to remain in practice in those areas.
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E.
Workforce diversity
•
F.
Create a provider workforce that is more representative of the people it serves.
National Service initiative: "Service for a Healthy America"
•
Sponsor a health-related National Service Program initiative.
A. NATIONAL HEALTH CARE WORKFORCE POLICY
Recommendation:
1.
A commissiop or other national body should be chartered to develop and
implement an explicit national health care workforce policy.
Rationale:
The transition to the new system will require careful attention to the health
care workforce in order to expand access generally while maintaining services
for vulnerable populations.
•
Coordination of government policy with professional organizations may
be needed to adjust criteria for approval of training programs, to
improve undergraduate and graduate health educational curricula, and to
design programs to retrain mid-career specialists as generalists.
•
Hospitals whose residency staff is decreased in the new system may
require support in order tp meet their service needs by hiring staff
physicians, physician assistants or advanced practice nurses.
Allocation of federal funds for graduate health education in a manner that
provides incentives to achieve national health workforce goals will require
leadership at the national level.
Continuing study and oversight will be necessary to refine criteria for the
receipt of federal funds, to improve administrative mechanisms to distribute
those funds, and to develop a general analytic and research capacity (including
a federal-state cooperative database to inform the public, educators and
policymakers).
11
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Recommendation:
2.
Substantial public investment in health care workforce training should continue.
•
Replace the current Medicare-only system for funding training with an "all
payor system" in which approximately one percent ($6.6 billion) of all
premiums would be placed into an educational fund.
•
Monies would be used to fund graduate health education for all primary
care providers (graduate medical education, graduate nurse and physician
assistant education); assist special programs to improve curricula, develop
faculty and retrain specialists; support programs to improve diversity;
improve provider availability in underserved areas; and research workforce
issues.
Rationale:
A small fraction of total health spending, used to promote constructive change
in the workforce, can make a significant difference in health care delivery.
There is so much public money currently invested in the workforce that a
prolonged transition would be required to remove it — a better approach is to
ensure that it is spent wisely.
If education and training were not subsidized, excessive personal debt would
discourage economically disadvantaged applicants and might distort practice
choices to favor more profitable fields.
The receipt by trainees of public fimds could be conditioned on providing
service if required to meet short-term needs in certain areas. This could range
from the current National Health Service Corps to universal service for recent
medical/advanced nursing graduates.
12
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Recommendation:
3.
There should be specific conditions, designed to address public needs, attached to
the receipt by training institutions of public funds for graduate health education.
•
The Secretary of Health and Human Services should establish requirements
and allocate funds with the guidance of the national commission and
recognized professional bodies.
All approved residency programs should be eligible to receive payments,
not just acute-care teaching hospitals.
•
Advanced nurse training programs and physician assistant training
programs should also be eligible to receive payments.
•
Funding should be provided preferentially to partnerships between
educational and community facilities (academic-community partnerships
or "consortia") in local areas that demonstrate results in conducting
community-based, interdisciplinary training, meeting local health care needs,
and increasing workforce diversity.
Rationale:
If public funds are invested rationally (no "blank check"), some allocation
process is necessary. The Workgroup believes that federal legislation or a
national commission should set clear requirements for funding, but
methods for achieving national goals should be left where possible to
communities, expert bodies and educational institutions.
An academic-community partnership is based on the idea that practitioners
will be better able to meet the needs of patients if the process of health
professions education and training takes place in an environment that
more closely resembles the real practice world. Under this model, the
federal, regional and expert bodies described below would establish outcome
and participation-based criteria for preferential receipt of funds, and
academic and community institutions would form partnerships in order to
qualify for those funds. An existing, successful example of an academiccommunity partnership for health education is the Area Health Education
Center (AHEC) (see Tab 11).
13
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Criteria for preferential receipt of funds might include:
Demonstrated recruitment of students from underserved urban and rural
areas.
Demonstrated retention of health professionals in the region served by
the partnership.
Demonstrated racial and ethnic diversity among trainees.
Demonstrated coordination of undergraduate and graduate health
education.
Consistency with national goals for training of primary care physicians.
Partnerships would form in order to qualify for preferential receipt of funds,
which would include graduate health education hinds and funds for special
projects.
An academic-community partnership would include a network of community
facilities (teaching hospitals, ambulatory care facilities, state and local public
health clinics, community/migrant health centers, rural clinics and other nonprofit health care organizations), academic institutions (academic health centers
and independent medical, nursing, dental and allied health schools) and
outreach sites (secondary and postsecondary schools, including community
colleges and technical schools)
•
Academic-community partnerships have many potential benefits:
•
Gives community facilities and non-physician professional
schools access to mainstream federal support for health
education.
•
Makes clear that recipients of public funds for health education
should be accountable to their communities and to the public.
•
Balances in-patient care skills with ambulatory care training and
training in cultural, ethnic/racial, preventive and public health
issues.
14
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Provides incentives to coordinate graduate and undergraduate
medical education.
Reinforces the importance of continuity in patient care and
instills community-based, cost-effective patterns of practice.
Improves awareness and acceptance of other professionals' skills
and promotes interdisciplinary team training.
Serves as a community laboratory in which to conduct research
on health services, medical outcomes and clinical management.
Increases community interest in health careers and promotes
practitioner diversity.
•
There are several ways to structure an entity to set criteria for the receipt
of graduate training funds or to allocate specific number and types of
training positions if direct allocation proves to be necessary.
•
Option A: national commission-ACGME linkage model: establishes a
cooperative arrangement ("deemed status") between a national commission
and existing professional regulatory bodies to allocate funds for advanced
training positions.
•
The Secretary of HHS and the commission would establish broad
funding criteria for, or determine the number of positions in, specialties
or groups of specialties, and would distribute funds (or positions) based
on the recommendations of the accrediting bodies described below.
•
The Accreditation Council for Graduate Medical Education (ACGME)
and the 24 Residency Review Committees (RRCs), would judge
programs based on educational quality and ability to meet national
criteria.
•
Equivalent professional bodies would assess quality of advanced nursing
and physician assistant programs.
15
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•
Option B: national commission-regional-state linkage model: establishes a
state or regional body to allocate funds in conjunction with a national
commission.
•
The Secretary of HHS and the commission would allocate
funding for residency positions and advanced nurse and
physician assistant positions to bodies, established by the
Secretary, in the ten HHS regions or in each state.
•
Regional bodies would include representatives of states, academic institutions,
ACGME, and advanced nursing and physician assistant accreditation councils.
•
Positions and funds would be awarded based on the ability of program to meet
regional goals, as well as on educational quality measures provided by
ACGME and nurse/physician assistant bodies.
B. PHYSICIAN AND NON-PHYSICIAN PRIMARY AND SPECIALTY CARE
PROVIDERS
Recommendation:
1.
Provide federal funding for the graduate training of advanced practice nurses and
physician assistants using the same mechanism that funds graduate medical
education.
•
Initially, so-called Medicare "GME-other" funds (approximately $300 million)
that currently support only acute care, hospital-based nursing could be applied
to "graduate nurse education" on a per trainee basis.
Rationale:
For equity, quality and cost-efficiency, the training of health care practitioners
capable of independently providing medical care should be supported in a
manner that does not favor one profession over another.
16
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Recommendation:
2.
Maintain or expand direct funding for graduate health education and allocate
fiinding in accordance with the commissiop, professional orregionaladvisory
bodies and/or academic-community partnership models described in (A)(3) above.
Rationale:
•
Direct educational support from an "all-payer fund" with outcome-oriented
requirements is an appropriate use of public monies.
•
The national commission or other national body will develop a transitional
plan to replace current indirect funding (IMEA) for teaching hospitals with
direct compensation, through premiums, for currently uncompensated care in
addition to supplemental payments for special clinical services provided by
those hospitals. This plan would be coordinated with the implementation of the
universal coverage in the new health system. (See briefing book for Academic
Health Center Workgroup.)
Recommendation:
3.
Over a five-year transition period, move to a national goal of at least 50%
primary care graduates of federally funded residency training positions (general
internal medicine, general pediatrics and family practice).
•
The 50% goal can be achieved by an explicit allocation process at the national
level or, depending on the allocation model selected (see (A)(3)), by delegation
to ACGME and residency review committees (and nurse/physician assistant
bodies) or to regional or state entities.
Rationale:
•
This recommendation is in accordance with other industrialized nations (the
United Kingdom has 73% generalists; Germany has over 50%) and with the
experience of closed-panel HMOs in this country. (See COGME — Tab 1)
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Recommendation:
2.
Do NOT attempt to control overall physician supply by limiting federally funded
graduate medical educatiop positions to a fixed percentage of the graduates of
American medical schools. (However, some members of the Workgroup believe that
financial incentives to enter specialties (e.g., fee-for-service payment) will remain too
strong to allow us to train enough primary care physicians and to control health care
costs without an overall limit on residency positions (whether or not federally funded)
of 110% of American medical school graduates.)
Rationale:
Comprehensive health reform should prevent physician overtraining or
oversupply from driving up total health care spending. After eliminating
existing perverse incentives, increasing the supply of physicians should drive
down prices and improve specialty and geographic distribution.
•
Annual premium payments to health plans will remove fee-for-service
incentives to overutilize and to specialize in high-technology fields.
•
Explicit payment for services to those currently uninsured and lower
compensation for subspecialty care by faculty practice programs will
reduce incentives for academic centers to train specialists and for large
teaching hospitals to use residents as inexpjensive service providers.
Universal coverage may increase the need for primary care physicians
beyond what can be produced by American medical schools with current
funding.
Service needs in underserved areas during the transition to the new system
could be endangered by losing residents.
Although many professional and public bodies have recommended limits
on total physician supply — including the Council on Graduate Medical
Education (see Tab 1), the PEW Health Professions Commission (see Tab 3)
and the U.S. Physician Payment Review Commission — these groups did not
address the problems of the medical workforce in the context of
comprehensive health reform, including the elimination of financial
incentives to overutilize expensive services and the need to provide care
(especially primary care) to the currently underserved.
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Even without limits, specialty societies may elect to reduce their memberships
in order to maintain higher prices for their services.
As mentioned in the Recommendation above, supply restrictions might be
required if fee-for-service incentives persist and high-cost specialty
practice remains attractive, or if public opinion favors limiting the receipt of
public monies to graduates of American medical schools.
•
Many primary care positions are filled by international medical
graduates (IMGs). Although many return to their countries of origin,
about 20% of U.S. practitioners are international medical graduates.
6
•
Because there is currently no limit on the total number of federally
funded positions, the number of first-year residents has increased by
6,000 over the last five years, substantially all of whom are foreignnational IMGs.
Recommendation:
3.
Encourage the devdopmept of programs to retrain specialist physicians interested
in moving into generalist careers through federal support of professional
organizations or academic-community partnerships,
Rationale:
•
Facilitation of retraining may be a more effective short-term intervention to
increase the supply of generalist physicians than changes in the distribution of
new graduates because only a small percentage of the workforce retires and is
replaced each year.
6
IMGs are foreign nationals or U.S. citizens who are graduates of foreign medical
schools.
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Recommendation:
4.
Require states to modify professional practice acts in specific ways in order to
level the playingfieldfor nop-physician primary care providers (see Tabs 6 and
IL
•
Require states to enact a definition of "advanced practice nurse" and to give
sole authority to state boards of nursing to determine qualifications (education
and experience) and scope of practice (including the authority to prescribe
drugs and devices) of advanced practice nurses.
•
Prohibit states from requiring physician supervision of or collaboration with
advanced practice nurses acting within their authorized scope of practice.
•
Prohibit states from requiring on-site physician supervision ("physical
presence") of physician assistants acting within their authorized scope of
practice.
•
Require states to allow physician assistants to prescribe drugs and devices if
approved by their supervising physician for conditions within their authorized
scope of practice.
Rationale:
Breaking down legal, regulatory and institutional barriers to the use of nonphysician providers is an effective short-term intervention, and will provide
diversity and improve access for rural and urban underserved areas as well as
promoting cost-effectiveness.
The debate over appropriate scope of practice will always be a political
one. Traditionally, political battles have been fought in forums that favor
physicians because of financial resources or established influence. The
suggested reforms are designed 1) to empower state boards of nursing
rather than physician organizations or private litigation to determine
advanced nurse scope of practice (i.e., a "home court advantage") and 2)
to overturn the most frequently abused legal barriers to efficient nurse and
physician assistant practice — prescribing power and ability to practice
without certain forms of supervision.
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The requirement that an advanced practice nurse be supervised in order to do
something within his or her authorized scope of practice has been employed
principally to require that services be reimbursed through a physician,
protecting physician revenue rather than patient safety.
Because of the distances involved, physician assistants in rural areas depend on
telephone rather than in-person contact with their supervising physicians.
The ability to prescribe medication is central to the provision of medical care.
Advanced practice nurses are entitled to practice certain forms of medicine;
they should also be allowed to prescribe medication within that scope of
practice. Physicians supervising physician assistants should be solely
responsible for authorizing prescriptions.
An efficient delivery network with good quality management will protect
patients better than current legal requirements. Especially with enterprise
liability, health plans and provider networks will have incentives to
ensure that non-physician practice is safe as well as cost-effective.
7
Recommendation:
5.
Request federal antitrust authorities and state insurance commissioners to police
anticompetitive practices by hospitals and health plans (refusals to grant
privileges^ malpractice insurers (refusals to insure or penalties on phvsicians
working with nonphysicians) and private payers (reimbursement policies) that
unfairly favor physicians over non-physician providers.
Rationale:
There are many subtle barriers to non-discriminatory practice. Federal and
state enforcement authorities should be encouraged to scrutinize and take
appropriate action against exclusionary practices.
7
Enterprise liability is a proposed malpractice reform that would make accountable
health plans responsible for injuries to their enrollees caused by their affiliated providers.
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Recommendation:
6.
Reimburse advanced practice nurses and physician assistants under Medicare and
Medicaid for services within their scope of practice under state law.
•
Current Medicare regulations reimburse only rural nurse practitioners. Current
Medicaid regulations reimburse only pediatric (family) nurse practitioners.
•
The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) contains
restrictions on nurse anesthetist practice that are inconsistent with state law.
•
Current Medicare and Medicaid reimbursement policies for physician assistants
providing primary care vary from state to state.
Rationale:
•
Federal reimbursement sends a clear message that services by nonphysicians are valued. Private payors are likely to follow the federal lead.
•
If the intent of the federal government is to leave decisions over scope of
practice to the states, it should avoid reimbursement policies that act as de
faclfi practice acts.
•
Capital to develop community-based provider networks (e.g., nurse-run
clinics) will be easier to obtain — this will help the transition to universal
coverage.
•
A legitimate concern, however, is the possibility of increased federal
spending resulting from potential increases in utilization during the transition
to a capitated payment system.
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Recommendation:
7.
Put into place additional, targeted federal programs to promote primary care.
Rationale:
•
Direct and guaranteed student loan programs (such as the Primary Care
Loan Program enacted in 1992) will prevent educational debt from forcing
students into specialty practice and will support students selecting primary care
careers.
•
An expanded National Health Service Corps will make medical education
more affordable and will provide needed service in rural and urban
communities.
•
Direct Federal support for primary care teaching programs, including
programs at Area Health Education Centers (see Tab 11) will help develop
community-based faculty.
•
The Health Career Opportunities Program, minority loan and scholarship
programs and minority faculty development programs will improve
workforce diversity.
C. BASIC NURSING AND ALLIED HEALTH OCCUPATIONS
Recommendation:
1.
Encourage states to review and revise their professional practice acts to recognize
the overlapping competencies of trained health professionals.
Rationale:
The Workgroup does not recommend the enactment of broad antidiscrimination legislation at the federal level because it would deter health
plans from making cost-efficient decisions, might breed litigation and would
tend to be either vague or overreaching.
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Recommendation:
2.
Fund targeted training programs (primarily using existing Title VII. Title VIII
(Public Health Service Act) and Department of Education (Perkins Act) funds) to
respond to current and projected needs for non-physician providers.
•
Expand authorization levels, appropriations and funding in existing laws that
support non-physician training. (Title VII P.L. 102-408: Area Health
Education Centers (AHEC), Health Education and Training Centers (HETC),
Geriatric Education Centers (GEC), Rural Interdisciplinary Training Programs,
AIDS Education and Training Centers (AIDS-ETC),
Allied/Associated/Dental/Public Health and Physician Assistant Programs).
•
Amend Title VII to expand eligibility requirements for training programs
(AHECs, GECs, Rural Interdisciplinary Training Programs, HETCs, AIDsETC) and to fund pilot programs for the training of multi-skilled technician
programs.
•
Appropriate the full authorized amount of $5 million in FY 1994 for Section
766 of Title VII of the Health Professions Education Amendments of 1991
(P.L. 102-408) to support advanced training to address faculty shortages.
•
Appropriate the full authorized amount of $5 million in FY 1994 for Section
767 of Title VII of P.L. 102-408, including stipend support of students who
will return to medically underserved areas and demonstration projects to
expand enrollment in allied health professions with shortages.
•
Redirect $16 million of Department of Education (Perkins Act) funds, which
total $1.2 billion to Title VII to expand support for associate degree level
allied health education, and include health vocational/technical education.
Rationale:
With universal coverage, the need for community nurses and allied health
professionals will increase.
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Recommendation:
3.
Restructure educational loan programs to include non-physician providers and to
emphasize loap forgiveness for practitioners in underserved areas and
recruitment and retention of minorities.
•
Expand student loan eligibility criteria to enable allied health students to
participate in the National Health Service Corps, Health Professions Student
Loan Program, and Health Professions Education Loan Program.
Rationale:
•
Aspiring health professionals from minority or disadvantaged backgrounds, who
are most likely to remain in or return to underserved areas, often lack the
financial resources to pay for their education.
Recommendation:
4.
Develop educational standards and provide fiinding under Title V I I Title V I I I
and Department of Education programs for educating and training long-term
care and mental health care providers.
f
Rationale:
•
The anticipated increase in demand for long-term and mental health care under
universal coverage will require additional well-trained providers.
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D. WORKFORCE
FOR UNDERSERVED RURAL AND URBAN AREAS
Recommendation:
1.
Implement incentives to encourage providers to enter practice in inner cities and
rural areas.
•
Remove existing restrictions on Medicare Graduate Medical Education funding
for, and provide additional financial incentives (such as preferential funding) to
encourage, education and training in community-based settings in
underserved areas.
•
Expand the National Health Service Corps and other loan forgiveness and
scholarship programs to cover all health professions and to give preference to
people from or committed to practice in underserved areas.
Rationale:
•
Providers are more likely to practice in the areas and settings where they are
trained. Limiting training to acute care hospitals leaves graduates ill-prepared
and unwilling to practice where they are most needed.
•
Because critical shortages exist and will worsen across a broad range of health
care providers, National Health Service Corps and other federal programs
should not limit eligibility to physicians and other advanced practitioners.
•
Scholarship and loan forgiveness programs are especially important to attract
economically disadvantaged candidates, including minority and rural students.
Recommendation:
2.
Implement policies and programs to encourage providers to remain in practice in
ipqer cities and rural areas.
•
Improve the rural health care infrastructure by coordinating federal
programs that provide infrastructure resources, such as the Rural Electrification
Administration, OSAP, the trauma bill and Cooperative Extension.
•
Improve the urban health care infrastructure with grant and loan programs
to community health clinics and to inner city hospitals that need to downsize
and update their facilities.
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Reduce professional isolation by supporting community-appropriate
continuing education, linkages with academic health centers (including
opportunities to train students and residents), state or regional locum tenens
(respite) programs, provider networks and interdisciplinary approaches to
training and practice.
Appropriate the full authorized amount of $7 million in FY 1994 for Section
778 of P.L. 102.408 to promote interdisciplinary training for health care in
rural areas.
Rationale:
The absence of infrastructure — equipment, facilities, staffing,
telecommunications and support services — prevents many underserved
communities from recruiting providers and sustaining their practice.
Isolated providers are neither efficient nor happy. Regional trauma networks
are an existing example of cooperative programs that use a team approach to
maintain services in rural areas.
Compensation for providers in underserved areas is, of course, an important
factor in practice decisions (see section (I)(B)(1) above). Increased payments
to providers of primary care in the new health care system is essential.
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E. WORKFORCE DIVERSITY
Recommendation:
1.
Implement policies and programs to create a provider workforce that is more
representative of the people it serves in terms of race ethnicity, culture and
f
geography.
•
Fund HHS Centers of Excellence Programs to reward health professional
schools for demonstrated excellence in educating minority students.
•
Expand HHS Health Careers Opportunity Programs to include secondary
schools with expertise in preparing minority youngsters for health professions.
•
Use the Disadvantaged Minority Health Improvement Act of 1990 (P.L. 101527) to award scholarships to disadvantaged students in the allied health
professions.
Rationale:
A racially and ethnically diverse workforce will:
•
Improve the supply of health care providers in underserved areas;
•
Overcome institutional prejudices that continue to deny care to
minority patients;
•
Provide care that is sensitive to cultural differences, communicate in
familiar languages and identify with the population that it serves;
•
Show patients and the public that there is equality of opportunity in
the health professions; and
•
Establish positive role models for youth.
The most substantial barrier to diversity is an insufficiently large pool of
minority applicants for health professional schools.
•
Professional schools should develop outreach partnerships with
community health centers, secondary schools, colleges and other
community organizations.
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•
Financial support and career development assistance must be available
to allow interested minority students to enroll and succeed.
Minority health care providers must also be encouraged to assume roles as
clinical faculty, research scientists and community leaders who can serve on the
local, regional and national bodies that develop and evaluate health policy.
F. NATIONAL SERVICE INITIATIVE: "SERVICE FOR A HEALTHY AMERICA"
Recommendation:
1.
Sponsor a national service initiative — "Service for a Healthy America" — to
link educational and career opportunities for secondary school and college
students and graduates with the provision of community health services in
partnership with the President's National Service Program.
•
A pre-college program targeted to help high-risk youth would include:
(1) "laddered" health vocations training and service opportunities; (2) academic
and social mentoring and support opportunities; (3) "stipend" support during
service; and (4) credit toward college tuition.
•
Programs for college students and graduates, including students in the health
professions, would offer: (1) opportunities to mentor and tutor pre-college
participants; (2) community-focused health careers for health professions
students; (3) skills and experience in community health outreach and education;
and (4) student loan assistance and credit for further study.
•
The program would be administered by HHS in association with the
President's National Service Program.
•
Funding would be provided by consolidating and redirecting existing
education and youth opportunities funds and by using new
appropriations.
•
The program would be implemented through ongoing grants (matching
funds with appropriate adjustment) to eligible community alliances that
include community organizations, health facilities and educational
centers.
•
Stipends and educational benefits would be consistent with other
National Service Program initiatives.
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Rationale:
Healthy communities are communities in which a commitment to young
people unites the health, education and economic sectors of society.
National leadership that brings together the opportunities and resources of these
sectors is essential if the related problems of health and youth are to be
addressed at the community level.
The National Service Program will reach out to high-risk and disadvantaged
youth, as well as to students who are considering or have entered health
professions, and will offer them vocational training, service stipends and
college tuition credit.
The program will provide meaningful support to the community components
of national health care reform — health departments, schools, community
clinics and outreach programs that emphasize primary care, disease prevention
and health promotion.
As well as instilling an ethos of lifetime national service in many of our future
citizens, the program will help underserved communities recruit and retain
health professionals that reflect America in all its diversity.
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m.
QUESTIONS AND ANSWERS
A. Does the U.S. have enough doctors and nurses?
Yes, in the aggregate the country has an adequate number of both doctors and nurses.
However, significant pockets of undersupply exist. Some patients, particularly poor people
in inner cities and rural areas, have difficulty obtaining general medical care and often
resort to emergency rooms as their usual source of care. The geographic maldistribution of
physicians that underlies these access problems is in part due to the fact that most physicians
are trained as specialists and require a substantial population base (of insured patients) to
sustain their practices.
The country continues to experience cyclical shortages of nurses, particularly in
hospitals. These shortages are primarily the result offluctuationsin relative wage rates rather
than an aggregate shortage of nurses. When nurses' wages fall relative to those of other
hospital workers, new positions are created for nurses because they can perform a wide range
of duties, from caring for critically ill patients to clerical activities. Although the hospital
sector should become smaller in the future, this phenomenon may continue in other practice
environments. Nonetheless, because a large number of nurses are currently trained for
hospital practice, there will likely be too many hospital nurses and the need will arise to
redirect nursing education to emphasize primary care in community settings.
B. Does the U.S. have the right kinds of doctors and nurses?
No, there are too many medical and surgical subspecialists and hospital-based
nurses, and too few generalist physicians (family physicians, general internists and
general pediatricians), advanced practice nurses, physician assistants and community
nurses. There are also shortages of certain types of physician specialists, such as general
surgeons and child and adult psychiatrists. The main cause of this imbalance, differences in
compensation between specialties, is also a major contributing factor to the high cost of
medical care.
Under the fee-for-service reimbursement system that has predominated during the
past thirty years, physicians who perform sophisticated procedures have earned more
than physicians doing "cognitive work." At the same time, federal support for physician
training (Medicare GME) has been paid only to "teaching hospitals," which tend to
emphasize specialty care for acute illness. An accompanying explosion of technology has
both fueled medical cost inflation and increased prestige for specialists. As a result, less than
one-third of U.S. physicians are primary care physicians, compared with 50-70% in other
industrialized countries. Specialists tend to have expensive practice patterns and to generate
demand for high-priced services.
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As a consequence of the growth of physician specialties under generous
reimbursement policies, nursing practice has increasingly been located in acute care hospitals.
In addition, community and public health nursing has lost strength because of reduced ftinding
for public services. Thesefinancialand cultural determinants of physician and nursing
practice have resulted in severe shortages of providers in certain areas, notably inner cities
and rural communities. Moreover, advanced practice nurses, such as nurse practitioners, have
been frustrated in their efforts to serve these communities by legal and institutional barriers
raised by physicians.
C. Why do we need a national plan for the training of health care workers?
The maldistribution of providers will become increasingly apparent as national
health reform is implemented. The currently underserved, many of whom live in rural areas
or inner cities, will be entitled to comprehensive medical care, mostly primary care services.
In addition, integrated delivery systems that develop to promote cost-efficiency without
sacrificing quality will depend to a greater degree on primary care providers, including
physicians, advanced practice nurses and physician assistants. Allied health professionals will
also be increasingly important as cost-effective providers of services in interdisciplinary team
settings.
The most constructive changes to the health care workforce will be produced by
restructured incentives in the practice market. Increased demand for primary care
providers should increase their compensation and draw trainees from other fields. Paying
teaching hospitals directly for the services they provide to the poor should reduce their need
to finance uncompensated care from "teaching funds" through overly expanded residency
programs. Capitated payments to health plans with accountability for access should increase
demand for doctors and nurses who care provide preventive services in community settings.
Unfortunately, obstacles exist that will impede these improvements unless national
leadership is available. Legal and institutional barriers to the efficient use of non-physician
providers need to be swept away. The current "blank check" support for hospital-based
graduate medical education produces too many of the wrong type of imperfectly trained
physicians. Schools of nursing and allied health have insufficient resources to increase
enrollment quickly. Rural areas and inner cities have been left behind for too long to be able
to attract providers without special help. Underserved minorities will not be pleased with the
health care that they receive until the provider workforce is much more racially, ethnically
and culturally diverse. One of the problems with our current approach to investing in the
health care workforce is that we have poured in a lot of money without requiring clear
results. To define those results and make sure that the training system achieves them requires
a national policy.
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D. Why should the federal government continue to subsidize the education and training
of health professionals?
It is in the public interest to have an accessible, diverse, high-quality health care
workforce. Without support, economically disadvantaged young people and those from
minority backgrounds and underserved areas would be unable to enter health care
careers. Although physicians earn five times the amount of the average American, the cost
of unsubsidized medical education and training would be prohibitive except to the very
wealthy.
In addition, because health care is a public good, public dollars should be used to
achieve national goals. A substantial federal contribution to health care training provides
a strong financial incentive for training institutions to work toward the objectives that
the market for services cannot achieve alone, such as practitioner diversity, training to
practice in community settings and underserved areas, and development of innovative allied
health programs.
E. How can we get a diverse workforce to provide community-based health services,
especially in rural areas and inner cities?
There is no single solution to the problems of diversity and access. Recruitment and
retention of providers are equally important, and highlight the need for a coordinated policy
for the health care workforce. Successful recruitment into underserved areas depends on
choosing the right people and providing them with the right skills. Minority trainees are
more likely to serve minority communities, and trainees from rural areas or inner cities are
more likely to return there. Developing this applicant pool requires a broadening of recruiter
focus beyond scientific and research skills, a carefully developed outreach program (especially
for underrepresented minorities) and afinancialcommitment to allow economically
disadvantaged young people to enter health care careers.
Education and training, particularly of physicians, have been narrowly concentrated on
intensive, hospital-based treatment of acute disease. Providers trained in these settings are
less likely to feel comfortable practicing in community settings. Health education must be
extended beyond the hospital walls into ambulatory care facilities, community clinics and
other sites, especially in underserved areas. Training in preventive services, racial and
cultural issues and cost-effective practice will help develop a workforce that is better able to
serve the entire country.
Retention of providers in underserved areas can be achieved through development of
infrastructure — facilities, communications, staff and support services — and through a
team and network approach that will reduce professional isolation. Increased compensation
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and prestige for primary care services is of course essential. Temporary providers serving in
the National Health Service Corps and other programs can assist during the transition and
can supplement permanent providers in particularly vulnerable areas.
F. Will the public be safe if we allow advanced practice nurses or physician assistants to
"practice medicine"?
Strict criteria for licensure have been necessary in our current system because there are
few sound methods of assuring quality and accountability of providers in practice. In the new
health care system, most providers will practice in accountable health plans. With federal and
state quality oversight, health plans will assure that they are being used safely as part of
total quality management. The strongest incentive for safe use of providers is enterprise
liability for medical malpractice — plans or institutions that bear the risk of injury to
patients caused by their affiliated providers will monitor their practice.
Advanced practice nurses and physician assistants have a long history of
providing high quality medical care. Nurse anesthetists predate physician anesthesiologists;
no differences in anesthesia outcomes have been found between physician and nurse
providers. Although institutional barriers limit practice of nurse midwives to approximately
3.4% of deliveries in the U.S., international comparisons suggest that they could safely
provide at least 75% of routine obstetrical care. Nurse practitioners prescribe medications
and provide comprehensive, general health care in a variety of clinical settings. Studies show
that advanced practice nurses can safely substitute for physicians for up to 90% of
pediatric and 80% of adult primary care, and physician assistant can safely perform at
least 60% of primary care tasks without consultation. According to the U.S. Office of
Technology Assessment, advanced practice nurses are "especially valuable in improving
access to primary care and supplementary care in rural areas and in health programs for the
poor, minorities, and people without health insurance," provide care "as good as or better
than care provided by physicians" and have "better communication, counseling and
interviewing skills than physicians."
G. Will we end up with a two-tiered system, with physicians in prosperous cities and
suburbs and non-physicians for everyone else?
Equalizing opportunities for physicians and non-physicians recognizes that both types
of professional have important roles to play in our health care system. As health networks
and integrated delivery systems develop, professionals from different backgrounds will
work together in interdisciplinary settings rather than merely substituting for one
another in solo practice. Physicians, advanced practice nurses and physician assistants are
not interchangeable — but all are well qualified to provide many needed primary care
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services. In the transition to universal access, it is likely that advanced practice nurses and
physician assistants will provide a substantial amount of service to the currently underserved
because they are quicker to train and more willing to work in rural areas and inner cities.
However, implementation of a clear national workforce policy will over time bring more
physicians into those areas while the national quality program will ensure the excellence
of the services provided.
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IV. POLITICAL CONSIDERATIONS
The Workgroup met with representatives of many professional and institutional bodies
and with individuals in private practice or affiliated with universities or other organizations.
In addition, some groups representing patients are very supportive of
recommendations to improve access to care delivered by non-physicians. For example,
groups interested in women's health issues favor allowing the public to choose nurses for
their primary care — nurse midwives have a strong following among middle-class, welleducated women. Women's groups also favor nurses' issues because nurses are primarily
women and women bear major burdens under the current system, such as not being able to
find or afford care for a sick child. The elderly, including the American Association of
Retired Persons (AARP), have been strongly in favor of greater access to non-physician
providers.
A. PROVIDER GROUPS
1. Nurses and Physician Assistants
We met with the following groups:
a.
b.
c.
d.
e.
f.
g.
American Nurses Association
National Black Nurses Association
American Association of Nurse Anesthetists
Association of Operating Room Nurses
Emergency Nurse Association
American Association of Nurse Practitioners and National Nurse Practitioner
Coalition
American Academy of Physician Assistants
In general, nursing groups want dramatic action rather than gradual or incremental
change. They are particularly interested in knowing what government entities will manage
the transition, and favor federal oversight by HHS. Maintaining quality of care is a key
concern, especially with respect to staffing cut-backs in hospitals. They favor support for
public health services, including those provided by nurses in communities and schools.
They require additional assurances with respect to these issues if they are to continue to
support the current health reform effort.
National Black Nurses Association's primary concern is access to services for minority
and underserved populations. They are also concerned about minority recruitment and
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minority faculty development. This group will pay close attention to workforce
development and scope of patient access to services. Because of their leadership role in
many communities, their influence with groups and individuals extends beyond health care.
Advance practice nurses are concerned about a number of issues. They believe that
reimbursement barriers are driving some nurses out of practice and are restricting access to
care for rural and underserved populations, and that state practice acts are restrictive and
severely hamper their ability to function fully within their scope of practice. They strongly
support federal preemption of state licensure restrictions, and legislation to ensure that
advanced practice nurses are not excluded from practice groups or health plans.
Advanced practice nurses are also concerned about minority issues. They support
educational incentives to promote practice in underserved areas. As with basic nursing, there
is concern among hospital-based advanced practice nurses that they will lose their jobs
as hospitals across the country lay off nurses "in anticipation of national health reform."
They also express the opinion that the ratio of ancillary personnel to registered nurses is being
raised to dangerously high levels as hospitals seek to save money by using semi-skilled
workers. They recognize that some hospital nurses will need to retrained for primary and
preventive care.
Unlike nurse practitioners, physician assistants do not desire the right to practice
independently of physicians. They are strongly in favor of uniform Medicare and
Medicaid reimbursement policies and the elimination of certain barriers to efficient
practice such as limits on prescriptive authority and restriction of "off-site" practice (where
they are supervised by telephone).
2. Allied Health Professionals
a.
b.
c.
Association of Schools of Allied Health Professions
National Society of Allied Health (minority allied health)
Hispanic Association of Colleges and Universities
These groups are concerned that support for allied health education programs does
not reach the limit of existing federal authorization. Few scholarships and loans are
available to students in professional allied health programs. They suggest that allied health
funding be reviewed in the context of increasing shortages of allied health personnel.
They recommend that the National Health Service Corps be extended to include
allied health professionals. They also are concerned that state practice acts restrict certain
allied health professions; however, they have not articulated specific legislative proposals.
They want allied health workers to be full participants in new delivery systems. They point
37
�FOR OFFICIAL USE ONLY
out that certain allied health workers can be cross-trained to provided a variety of needed
services in underserved and rural areas — for example, radiology technicians can be trained
to perform laboratory tests and act as medical records assistants. Project grants are needed to
develop these multi-disciplinary training programs.
Because only three percent of allied health workers are minorities, they feel that
special minority scholarships or grants should be available. There are also insufficient
minority faculty to serve as role models. They observe that allied health professionals are
in short supply in the Midwest and rural states because the educational programs tend
to be located in the East and West. Faculty development and program expansion are
needed to alleviate this problem.
3. Physicians
a.
b.
c.
d.
American Medical Association
American College of Physicians
American Academy of Family Physicians
American College of Obstetrics and Gynecology
Physicians are split on many issues. As many physician groups are opposed to most
recommendations as favor them. The American Medical Association (AMA) tends to be
much more conservative than the specialty societies and other national groups such as the
American College of Physicians. Most physician groups recognize the need to increase the
number of primary care physicians and to constrain the growth of specialty practice.
They observe that it is not merely a "numbers problem," but reflects geographic
maldistribution and, to some extent, inadequate provider diversity.
The AMA and a substantial number of physicians are opposed to granting
autonomy to other health professionals. The opposition is particularly intense at the state
level in battles over state practice acts. The AMA can be expected to oppose all proposals to
remove barriers to practice by non-physician providers, and to oppose the training of more
advanced practice nurses and their inclusion as primary care providers in the new health
system. The family medicine organizations also tend to oppose the concept of nurse
practitioners since they think of primary care as solely within their purview.
It should be remembered, however, that physicians played a central role in
recommending the development of advanced practice nurses and physician assistants, and that
much of the research demonstrating their safety and cost-effectiveness has been published by
physicians. Pediatricians, internists, and ob/gyns are on record favoring advanced
practice nursing.
38
�FOR OFFICIAL USE ONLY
B. ACADEMIC INSTITUTIONS
1. Teaching Hospitals and Medical Schools
a.
b.
National Association of Public Hospitals
Association of American Medical Colleges
Public hospitals or teaching hospitals serving a large number of poor patients are
primarily concerned about how to provide medical care to hospitalized patients. They oppose
limits on the number of residency positions and oppose limiting specialty training
positions. Directors of hospitals are concerned that downsizing of residency positions or
federal funding would create "havoc" in the larger teaching hospitals because residents
provide most of the medical care in these institutions. They contend that, unless they
receive a generous transitional "pass through" or other special subsidy, they do not have the
resources to employ full-time physicians or non-physicians to replace residents.
The Association of American Medical Colleges (AAMC) favors a national policy
of promoting primary care and is considering the question of limits on total residency
positions. No consensus appears to have emerged. Deans of medical schools are concerned
about the continuation of GME funding for teaching, patient care and research, and seem to
"fear the worst" from the health reform effort. Many favor a level playing field between
teaching hospitals and other sites for the receipt of funds, and some express approval of
"consortium" models. The AAMC favors using more advanced practice nurses to substitute
for residents.
2.
Nursing Schools
a.
American Association of Colleges of Nursing
We met with a panel of nursing school deans and with representatives of the
American Association of Colleges of Nursing (AACN). The deans are concerned that most
federal funding of basic nursing education goes to diploma programs in hospital schools
of nursing (Medicare "GME-other") and associate degree programs in community colleges
(Department of Education funds), while only baccalaureate programs prepare nurses for
primary care practice in community settings. They believe that there is a surplus of
hospital nurses and a shortage of community nurses and want federal funds rechanneled into
baccalaureate programs. The deans also note a large demand for advanced practice nurses.
They will need additional federal funding to expand graduate programs to meet cunent and
future needs.
39
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�FOR OFFICIAL USE ONLY
Tab 1
This section includes:
Council on Graduate Medical Education
Council on Graduate Medical Education (COGME) Third Report: Improving
Access to Health Care Through Physician Workforce Reform. Health
Resources and Service Administration (October 1992).
�SUMMARY
Council on Graduate Medical Education (COGME) Third Report: Improving Access to Health
Care Through Physician Workforce Reform. Health Resources and Service Administration
(October 1992).
COGME was authorized by Congress in 1986 to provide an ongoing assessment of physician
workforce trends and to make recommendations to the government and private sector. This
report provides the Council's findings, goals and recommendations to address the major
physician workforce issues ~ the supply and distribution of physicians and its impact on access
to care.
The Council offers a number of recommendations, of which the following are the most
important. One. establish a national Physician Workforce Commission and state commissions
to determine local, regional and national needs. Two, implement the workforce plan through
local, state or regional medical schools or teaching hospitals. Three. allocate residency
positions and graduate medical education (GME) funding based on state and regional
workforce needs. Four, provide GME financial incentives, through Medicare and other payers,
to train more generalists and fewer non-primary care specialists and subspecialists. Five.
increase incentives for primary care practice and service in inner-city and rural areas through
physician payment reform, loan programs and differential reimbursement for practice in
shortage areas.
�Executive Summary
COUNCIL ON GRADUATE MEDICAL EDUCATION
Third Report
Improving A c c e s s to Health Care
Through Physician Workforce Reform:
Directions for the 21st Century
Changing the Physician Supply
Increasing Minority Representation in Medicine
Reforming Medical Education
October 1992
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
Health Resources ind Services Administration
�THIRD REPORT Of COGME - EXECUTIVE SUMMARY
ble of Contents
Highlights
Findings
Goals
Recommendations for the Nation
Spedfic Recommendations for Medical Educators
Executive Summary
Findings and Goals
Finding No. 1
Finding No. 2
Finding No. 3
Finding No. 4
Finding No. 5
Finding No. 6
Finding No. 7
Recommendations for the Nation
National Physician Workforce Goals
Physician Workforce Infrastmcture
Financing the Physician Workforce Plan
Specific Recommendations for Medical Educators
Mission Statement and Strategic Plan
Recruitment, Adn^sions, and Retention Policies
Faculty Composition
Medical Education Objectives
Achieving a More Integrated and Balanced
Medical Education Curriculum
Expanding the Medical Education Teaching Environment
Background, Charge, and Principles of COGME
Charge to the Council
Previous Reports
Principles of the Council
Issues for Further Exploration
COGME Members, Subcommittees, and Staff
Members
Council Subcommittees
Physician Manpower Subcommittee
Medical Education Programs and Financing Subcomminee
Minority Representation in Medicine Subcomminee
Staff
5
5
6
6
6
7
8
8
8
9
9
9
10
10
11
11
11
12
15
15
15
15
15
16
16
17
17
17
17
18
19
19
20
20
20
20
20
�•mtRO REPORT OF COGME • EXECUTIVE SUMMARY
•
ghlights
Findings
The Council's seven majorfindingsidentify a series of deficiencies in the current
physician supply, medical educationfinancing,and health care reimbursement systems
which hinder health care access. The Council'sfindingsconclude that the Nation has:
• Too few generalists ('
cians ) and too many nonf
family physician: »neral internists, and general pediatriiry care specialists and subspecialists.
• Access to care prob u in inner-city and rural areas that are growing despite
substantial increases in the total physician supply.
• Too few underrepresented minoriiy physicians.
• Shortages in certain nonprimary care medical specialties, including general su
gery, adult and child psychiatry, and preventive medicine, and among generalist physi
cians with additional geriatrics training.
• An increasing physician-to-population ratio, which will do little to improve the
public's health or increase access and will hinder cost-containment efforts.
• A system of undergraduate and graduate education that can be more responsive
these regional and national workforce needs.
• No national physician workforce plan or sufficient incentives in medical educatio
financing and health care reimbursement to attain the appropriate specialty mix. raci
ethnic composition, and geographic distribution of physicians.
Goals
Based on thesefindings,COGME recommends adoption of the following nationa
physician workforce goals. The United States should:
• Move toward a system in which 50 percent of physicians practice in the generalis
disciplines offamily medicine, general internal medicine, and general pediatrics.
• Increase to at least 50 percent the percentage of residents who complete a three-yea
training program in family medicine, general internal medicine, and general pediatr
and enter generalist practices.
• Improve physician distribution to eliminate primary medical care shortage area
and urban/rural disparities.
• Double the number of entering underrepresented minority medical students fro
1^00 to 3,000 by the year 2000, a goal established by the Association of American
Medical Colleges.
• Increase the number of general surgeons, preventive medicine specialists, adult a
child psychiatrists, and general internists andfamily physicians with additional geriatri
training.
�THIRD REPORT O f COGME - EXECUTIVE SUMMARY
• Maintain the osteopathic and allopathic physician-to-population ratio at current
levels.
Recommendations for the Nation
The centerpiece of COGME's recommendations is the establishment of a workforce
plan, rational medical education infrastructure, and financing strategy to attain the
national physician workforce goals. Recommendations include:
• Establishing a National Physician Workforce Commission and State Commissions
to determine local, regional, and national needs.
• Implementing the workforce plan through local, State, or regional academic consortia, which might include one or more medical schools, teaching and community hospitals,
health maintenance organizations (HMOs), community health centers, and other educational and teaching institutions or agencies.
• Allocating residency positions and graduate medical education (GME) funding
based on State and regional workforce needs and national goals for aggregate physician
supply, minority recruitment and retention, and specialty distribution.
• Encouraging allopathic and osteopathic medical schools to not increase enrollment.
• Capping Medicare (and other) funded first-year residency positions at 10 percent
more than the number of US. allopathic and osteopathic medical graduates.
• Providing undergraduate financial incentives, including loan and scholarship programs, to recruit and retain more underrepresented minorities and graduate more
generalists.
• Providing GME financial incentives, through Medicare and other payers, to vain
more generalists and fewer nonprimary care specialists and subspecialists.
• Increasing incentives for primary care practice and service in inner-city and rural
areas, through physician payment reform, reduction ofadmi•"'strative burdens. National
Health Service Corps (NHSC) scholarship and loan programs, tort reform, and differential Medicare and Medicaid reimbursement for practice in shortage areas.
Specific Recommendations for Medical Educators
A physician workforce plan andfinancingstrategy will help our Nation respond to
societal needs for more minority and generalist physicians and for access to more
primary care services, particularly in underserved inner-city and rural areas. Achieving
these national workforce goals will also require the commitment and leadership of our
Naiion's medical educators. The Council's vision of a medical education system that is
responsive to our Nation's health care needs in the 21st century will be reflected in the
insiixution s:
• Mission statement and strategic plan.
' Recruitment, admissions, and retention policies.
• Medical education objectives and curricula.
• Faculty composition and reward system.
• Medical education and teaching environment.
• Linkages with a variety of teaching sites.
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
ecutive Summary
I
n 1988, when COGME issued itsfirstreponto
the Secretary of the Depanmeni of Health and
Human Services (DHHS) and Congress, it expressed concern that physician specialty and geographic maldistribution was growing despite an increasing aggregate supply of physicians. At that
time, concerns about access to health care and rising heaith care costs had not yet been thrust into the
national spotlight. Similarly, physician workforce
policy was not high on the national agenda.
6. Can our medical education system be more
responsive to the health care needs of the Nation?
7. What are the factors that have hindered
efforts to attain the appropriate composition, specialty mix, and geographic distribution of physicians to ensure access to care for all Americans?
Over the two-year period since its last report,
the Councilreceiveda broad range of input. This
included solicited papers covering supply and demand for physician workforce, barriers to access to
physician services, and updated need-based requirements for selected specialties. The Council Umited
itsreviewof workforce assessments to the following specialties: general/family practice, general
internal medicine, general pediatrics, general surgery, obstetrics/gynecology, adult and child psychiatry, preventive medicine, and the area of geriatrics as an added qualification to family practice and
internal medicine.
The historical context of thisreponis vastly
different. Today, the health care system is acknowledged to be in crisis. While health care expenditures exceeded S650 billion in 1990 and are
projected to reach Sl trillion in 1995. 37 million
Americansremainmedically uninsured, and millions more face barriers to basic health care. Furthermore, the Nation's basic health status indicators, which are in some measure influenced by
access to health care, lag behind most economically
developed countries. There is now recognition that
The Council received significant testimony at
health carereformto ensure all Americans access plenary sessions and before its three subcommittees
to basic care is not possible without physician
on Physician Manpower, Medical Educauon Proworkforce refonn.
grams and Financing, and Minority Representation
in Medicine. Representatives from major organizaIt is in this context that COGME has been
tions and policy-making bodies, including the maexamining physician workforce supply and distrijor allopathic and osteopathic ho^ital and medica!
bution and its impact on ensuring access to care for
education organizations and major specialty org^
all Americans. Over the past two years, the Counnizations, have testified on aspects leading to thL
cil has focused on the following seven major questhirdreport.Major foundations have provided testions:
timony, including the Josiah Macy, Jr. Foundation,
the Roben Wood Johnson Foundation, the Pew
1. Do we have an adequate mix of generalists and specialists to provide the most efficient and Charitable Trusts, and the Kellogg Foundation. Repthe most cost-effective system of quality care for all resentatives of State and local concerns, such as the
New York State Council on Graduate Medical EduAmericans?
cation and the National Conference of State Legis2. What implications do problems of access latures, also testified. In addition, COGME has
have for recommendations on physician workforce, reviewed the latestrecommendationsfrom medical
supply, and distribution?
educators and policymakers on medical education
3. What is the status of minority representa- reform policy.
tion in medicine and what effect does it have on
This third report to Congress and the Secretary
minority health as well as the health ofthe public in
of DHHS provides the Council's findings, goals,
general?
and recommendations to address these major physi4. What are the supply needs of specific medi- cian workforce issues of today and the underlying
principles lhat guided its deliberations.
cal specialties?
5. Do we currently have adequate numbers
of total physicians? Will the projected supply of
physicians be adequate?
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
•
ndings and Goals
Finding N o . 1
The Nation has too few generalists and too
many specialists.
contribute to the problems of access, including economic and social circumstances of rural and innercity areas as well as the shortage of minority and
generalist physicians.
Goal: The United States should move toward a
health care system in which 50 percent of physicians pracdee in the generalist disciplines of family
practice, general internal medicine, and general pediatrics. Consequently, at least 50 percent of residency graduates should complete a three-year training program and enter practice as generalists.
• Minority physicians and physicians in the
three primary care specialties (family practice, general internal medicine, and general pediatrics) are
more likely to serve inner-city populations. Family
physicians and general surgeons are more likely
than other specialties to serve rural populadons.
The decline in numbers of general surgeons enter• The growing shortage of practicing general- ing rural practice is littlerecognizedand has sigists (i.e., family physicians, general internists, and nificant implications for access to trauma services
general pediatricians) will be greatly aggravated by in rural settings and to the fiscal viability of rural
the growing percenuge of medical school gradu- hospitals.
ates who plan to subspecialize. The expansion of
• Consequently, more minority and generalist
managed care and provision of universal access to physicians must be educated and educational procare will only funher increase the demand for gen- grams should specifically address skills needed in
eralist physicians.
these settings. This must be accompanied by sufficient incentives to enter andremainin inner-city
• Increasing subspecialization in U.S. health
care escalates health care costs, results in fragmen- and rural practice and the development of adequate
health care systems in which they can practice.
tation of services, and increases the discrepancy
between numbers of rural and urban physicians.
• Access to one imponant component of primary medical care, obstetrical services, has been in
the national spotlight. Problems are greatest Lr.
rural and inner-city areas. Causes include economic and sociocultural factors and the availability
of obstetricians, famfly physicians, and nurse midwives. While the total number of obstetricians
continues to increase, the proportion providing obstetrical services decreases dramadcally with the
number of years in practice.
• A rational health care system must be based
upon an infrastructure consisting of a majority of
generalist physicians trained to provide quality primary care and an appropriate mix of other specialists to meet health care needs. Today, other specialists and subspecialists provide a significant
amount of primary care. However, physicians who
are trained, practice, and receive continuing education in the generalist disciplines provide more comprehensive and cost-effeciive care than nonprimary
• Less than 10 percent of obstetricians practice
care specialists and subspecialists.
in rural settings. Consequently, family physicians
historically provide the majority of rural obstetrical
Finding N o . 2
care. In recent years, however, the proponion of
family physicians providing obstetrical services has
Problems of access to medical care persist
also markedly declined. Whilerisingmalpractice
in rural and inner-city areas despite large
claims clearly have contributed to the decreasing
increases in the number of physicians
provision of obstetrical care, other factors such as
nationally.
unpredictable hours, also seem to have contributed
Goal: All primary medical care shortage areas to these decisions.
should be eliminated and disparities between the
metropolitan and nonmetropolitan distribution of
physicians should be reduced.
• Access to primary care services is especially
difficult in rural and inner-city areas. Many factors
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
Finding No. 3
The racial/ethnic composition of the
Nation's physidans does not reflect the
general population and contributes to
access problems for underrepresented
minorities.
• The future growth in general surgical service,
is likely to exceed the growth in the supply of
general surgeons. Aging of the U.S. populadon
will increase demand for surgical services, and the
number of physicians in general surgery is inadequate to meet a growing need for trauma care
services and for surgical care in rural areas. The
training curricula for general surgery need to be
broad-based to ensure that graduates have sufficient knowledge and skills to manage the wide
array of surgical problems that may be seen in rural
and inner-city areas.
Goal: The racial/ethnic composition of the physician population should reflect the overall
population's diversity. The Nation should adopt
the goal of the Association of American Medical
Colleges to double the number of first-year entering underrepresented minority medical students from
• The burden of psychiatric illness in both chilU00 to 3,000 by the year 2000.
dren and adults indicates a need for more psychiatrists and chi' psychiatrists. However, effective
• Although African Americans, Hispanic
.iatric care is constrained by limAmericans, and Native Americans compose 22 per- demand for;
ited insurance /erage.
cent of the total population and will constitute almost one-fourth of all Americans by the year 2000.
• Continued shortagesremainin the field of
they represent only 10 percent of entering medical
preventive medicine, which includes specialty arstudents, 7 percent of practicing physicians, and 3 eas of public health, general prevendve medicine,
percent of medical faculty.
occupational medicine, and aerospace medicine.
These physicians make significant contributions to
• Increasing the percentage of underrepresented
our Nation's year 2000 health objectives. Although
minorities in the medical profession is vital as a
means of improving access to care and health status four qualified students apply for each training slot,
the greatest banier to training physicians in preven
of these vulnerable and underserved populations.
Minority physicians tend to practice more in minor- tive medicine is the virtual absence of GME fundity/underserved areas, reduce language and cultural ing.
barriers to care, and provide much needed commu• Additional emphasis is warranted in the area
nity leadership.
of geriatrics, given the aging of the population.
Family physicians and general internists must be
• Strategies to increase minority enrollment
trained to provide comprehensive care for the eldmust emphasize increasing and strengthening the
erly. Strategies should be developed to train more
applicant pool, the acceptance rate from within this
pool, and the student retention rate. These strate- generalist physicians and suppon those who are
gies must take into account disproportionately high interested in pursuing additional training in geriatrics.
rates of poverty, poor health status, poor schools,
and a continued lack of access to educational and
career opportunities. They must include both tradi- Finding No. 5
tional short-term effons and long-term strategies
Within the framework ofthe present
targeting younger students early in the education
health care system, the current physicianpipeline.
to-population ratio in the Nation is
adequate. Further increases in this ratio
Finding No. 4
will do little to enhance the health of the
public or to address the Nation's problems
Shortages exist in the specialties of general
of access to health care. Continued
surgery, adult and child psychiatry, and
increases in this ratio will, in fact, hinder
preventive medicine and among generalist
efforts to contain costs.
physicians with additional geriatrics
training.
Goal: The aggregate allopathic and osteopathic
physician-to-population ratio should be maintained
Goal: The percentage of physicians trained
and certified in the specialty fields of general sur- at current levels.
gery, adult and child psychiatry, and preventive
• Efforts to solve problems of access to health
medicine, and the percentage of family physicians care by increasing the total physician supply have
and general internists with addiuonal geriatrics train- been largely unsuccessful A growing physician
ing should be increased.
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
10
oversupply is projected, which will hinder efforts to
• There is no national physician workforce plan
contain costs.
for the United States to meet the current and pro• Consequently, the number of physicians edu- jected future health care needs of the American
people. In addition, there is no coordinated financcated should be reduced. Strategies to improve
access to care should, instead, focus on altering the ing strategy and integrated medical educauon system to implement such a plan. Instead, such critical
specialty mix,racial/ethniccomposition, and geopolicy issues as the aggregate physician supply and
graphic distribution of physicians.
specialty mix are theresultof a series of individual
decisions made by the 126 allopathic and 15 osteoFinding No. 6
pathic medical schools and nearly 1,500 institutions and agencies that currently sponsor or affiliate
The Nation's medical education system can
with GME training programs.
be more responsive to public needs for
more generalists, underrepresented
• The medical education financing and health
minority physicians, and physicians for
carereimbursementsystems create significant barmedically underserved rural and inner-city
riers to students who wish to become generalists,
areas.
physicians who wish to practice in underserved
Goal: Undergraduate and graduate medical edu- areas, and to the provision of basic primary care
cation should increase its emphasis upon meeting and preventive services to all Americans.
regional and national physician workforce needs.
• The Nation's system of undergraduate and
graduate medical education, taking place in 141
osteopathic and allopathic medical schools and in
more than 1.500 institutions and agencies, has responded effectively to many of the Nation's health
care needs. During the past 25 years, our Nation's
medical education system hasrespondedto public
demands to increase the numbers of physicians,
advance biomedical research, and develop new
medical technology. These responses have resulted
in a doubling of the physician supply and the establishment of a biomedicalresearchand medical technology infrastructure that is unsurpassed.
• Today, the medical education system must
respond to the Nation's health care and physician
workforce needs in the 2lsi century. These include
the need for more minority and generalist physicians, more primary care research, and increased
access to primary care, particularly in underserved
rural and urban communities. Changes in the institutional mission, goals, admissions policies, curriculum, faculty composition and reward system,
and the site for medical education and teaching are
necessary torespondto these needs.
Finding No. 7
The absence of a national physician
workforce plan combined with financial
and other disincentives are barriers to
improved access to care.
Goal: In order to improve access to care, a
national physician workforce plan, infrastmcture,
and approach should be established that combines
financial and other incentives and disincentives to
achieve national physician workforce goals.
�THIRD REPORT O f COGME - EXECUTIVE SUMMARY
•
11
commendations for the Nation
A
n adequate supply, mix, and distribution of
cal and osteopathic medical schools. At the
physicians and other health professionals
same time, medical schools should maintain
is needed to ensure basic and essential
and expand their commitment to recruiting mihealth care to all citizens. Deficiencies in the
nority students and training generalists.
Nation's medical education financing and health
• The total number of entryresidencypositions
care reimbursement systems significantly hinder
should be limited to the number of U.S. allopathic
our ability to achieve this fundamental goal. The
and osteopathic medical school graduates plus
Council recommends the following measures which,
10 percent (exceptions should be made for exif implemented, would establish a national physichange visitor international medical graduates).
cian workforce plan and infrastructure o meet the
Nation's basic health care needs in the 21st century. Physician Workforce
National Physician Workforce
Goals
Infrastructure
2. Congress should establish a National Physician Workforce Commission to develop and rec1. The Nation should adopt the following over- ommend the necessary policies to attain the naall national physician workforce goals to ensure the tional physician workforce goals, project and moniproper supply, mix, and distribution of physicians tor physician workforce trends, andrevisethe
needed to ensure access to basic and affordable workforce goals and policies as necessary. Thi'
health care for all Americans:
new entity should*
a. The provision of health care in the United
a. Serve in an advisory capacity to the Secretary
States should be based upon a system in which
of DHHS and all appropriate congressional
50 percent of physicians practice in the generalcommittees with jurisdiction involving underist disciplines of family practice, general intergraduate and graduate medical education.
nal medicine, and general pediatrics.
b. Make recommendations on Federal and other
b. All primary care shortage areas should be
financing of medical education.
eliminated and disparities between the metroc. Have broad representation, including physipolitan and nonmetropolitan distribution of
cians, medical educators, students, residents,
physicans should be reduced.
and representatives of hospitals, HMOs, comc. The racial/ethnic composition of the physimunity health centers, business, labor, governcian population should reflect the overall
ment, third-pany payers, and consumers.
popularion'sdiversity. The Nation should adopt
d. Have an adequate State andregionalphysitheAssociation of American Medical Colleges'
cian workforce data base from which to evalugoal of increasing the number of first-year enate trends and make recommendations.
tering underrepresented minority students from
1,500 to 3.000 by the year 2000.
e. Have sufficient staff and funding to permit its
effective operation.
d. The percentage of physicians trained and
certified in the specialty fields of general surf. Coordinate its recommendations with the
gery, adult and childpsychiatry, and prevendve
Physician Payment Review Commission and
medicine should be increased.
the Prospective Payment AssessmentCommission.
e. The percentage of family physicians and
general internists who receive additional traing. Replace COGME and assume its charge.
ing in geriatrics should be increased.
3. States should be encouraged to establist
f. The aggregate allopathic and osteopathic phy- State or regional Physician Workforce Commissician-to-population ratio should be maintained sions to study physician workforce needs and trends
at current levels. Consequently:
and set workforce goals. The State Commissions
• There should be no increase in the aggregate should have broadrepresentationof key leaders in
number offirst-yearenrollments in U.S. medi- medical education, and representatives of profes-
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
12
sional communities, hospitals, HMOs, community
health centers, business, labor, government, thirdparty payers, and consumers.
Financing strategies must address undergraduate and graduate medical education, as well as the
physician practice setting. The following is one
approach toward achieving these goals. The Coun4. The National Commission should be respon- cil expects to continue to study additional options
sive to the workforce needs identified by State Com- as pan of its future work.
missions and develop a mechanism to facilitate
cooperation ' nd collaboration between itself and
A. Undergraduate Medical Education
the S tate ant
ial enti ties.
7. Each medical school should establish and
5. General principles that should be considered attain objectives for the composition and specialty
by the National Physician Workforce Commission mix of its graduates in suppon of the above nauonal
include the following:
goals.
a. The national workforce plan could be imple8. Financial incentives must berealignedto
mented through local. State, and regional aca- reward medical schools for recruiting more
demic consortia. Each academic consordamight underrepresented minorities and for graduating more
include one or more medical schools, teaching future family physicians, general internists, and genand community hospitals, community health
eral pediatricians. The majorrevenuesources of
centers, HMOs, and educational institutions
undergraduate medical school budgets are Federal
from primary school through college.
and State funds and income generated from faculty
b. Under this plan, residency positions and practice plans. Federal and State strategies to inGME funding should be allocated based on
crease minority representation and the production
S tate andregionalworkforce needs and national of generalists must focus on these funding streams.
goals for aggregate physician supply, minority
9. Primary care scholarships and/or low interrecruitment, and specialty distribution.
est rate loans should be established for students
c. All payers should contribute to GME, includ- who commit themselves to generalist careers. Funding Medicare, Medicaid, private insurers, self- ing would have to be repaid if the graduate chooses
insured employee plans, and HMOs and other a nonprimary care specialty or subspecialty.
managed/coordinated care systems.
10. Public and private incentives should be
d. The funds from the Public Health Service, increased to assist medical schools inraisingthe
Health Care Financing Administration, and pri- minority applicant pool selecting more minorities,
vate sources should be utilized to assist in meet- retaining more minority students, and expanding
ing overall physician workforce goals.
the number of minority faculty.
Financing the Physician
Workforce Plan
6. A multifaceted incentive/disincentive approach should be used to achieve these workforce
goals. The net impact of any financing strategy
must, therefore, be to suppon the'following goals:
• To increase the number of underrepresented
minorities recruited.
• To increase the number of medical graduates
entering generalist medical practice to at least
50 percent and concurrently decrease the percentage who choose subspecialties.
• To increase the number of general surgeons,
adult and child psychiatrists, and preventive
midicine specialists.
• To increase the number of family physicians
ar.d general internists receiving additional training in geriatrics.
• To eliminate primary medical care shortage
a.reas.
a. Funding to the DHHS Centers of Excellence
program should be increased to reward medical
schools for demonstrated excellence in educating minority medical students.
b. Funding to the DHHS Health Careers Opportunity Programs should be increased, and the
program expanded to secondary schools, such
as magnet high schools, with expertise in preparing underrepresented minority youngsters
for the health professions.
c. A national minority recruitment/counseling
advisory clearinghouse should be established to
assist and beaerprepare potential medical school
applicants from underrepresented minority
populations.
d. The private sector should be encouraged to
support the nationwidereplicationof programs
lhat have been successful in increasing the minority applicant pool.
�THIRD REPORT OF COGl
EXECUTIVE SUMMARY
13
e. Active collaboration among major medical The following is one approach toward these goals:
groups, such as the American Medical Associaa. Medicare direct and indirect GME payments
tion, Association of Amencan Medical Colshould be limited to residency training for initial
leges, National Medical Association, Associacertification orfiveyears, whichever is less.
tion of American Indian Physicians, and the
Residency programs in preventive medicine
InterAmerican College of Physicians and Surshould also receive Medicare GME payments.
geons, should be encouraged with the goal of
There should be exceptions to initial certificaincreasing minority recruitment and retention.
tion limits for training in child psychiatry and
geriatrics.
11. Government should assist medical schools
in developing a critical mass of faculty in the generb. Increased direct medical education (DME)
alist disciplines. This critical mass of strong acapayments should be allocated to family practice
demic faculty will assist in providing an educaresidency programs.
tional milieu that fosters selection of a primary care
c. Increased DME payments should be :
specialty.
cated tc temal medicine and pediatric
a. Funding through the Nauonal Institutes of
dency ; rams that develop an agreed-.
Health and the Agency for Health Care Policy
curricui that specifically prepares grada:.-is
and Research should be increased for research
for primsry care practice. These increased
in primary care, health services delivery, and
payments will reimburse programs fes-the higher
panent care outcomes, as well as for the develcosts of training in the primary care setting.
opment of research faculty in the primary care
d. Incentive salaries should be made available to
disciplines.
residents in family practice, internal medicine,
b. Title VU grants to assist in the development
and pediatrics, who sign a contract indicating
of Depanments of Family Medicine should be
their intention to complete their three-year promaintained and new funding should be made
gram and enter generalist practice, with a yearavailable to assist in strengthening Divisions of
by-year payback for those who choose to
General Internal Medicine and Pediatrics.
subspecialize.
c. Physician payment refonn must continue and
e. Because residents in allopathic family pracshould be extended to private payers to correct
tice and osteopathic general practice programs
the imbalance between the income generated by
are more likely toremaingeneralist physicians
generalist and subspecialist faculty practice
and practice in needy rural areas than other
plans.
physicians, incentives to increase the numberof
fam ily practice and osteopathic general practice
12. Government should assist medical schools
residents should be a high, shon-term priority.
in their effons to increase education in ambulatory
and community settings.
f. Because of the significant decline in internal
medicine and pediatric graduates completing
a. Title VII grants for predoctoral education
three-yearresidenciesand entering generalist
should be expanded to assist medical schools in
careers and the concurrent growth in those choosenhancing education in the primary care speing to subspecialize,both disciplines are strongly
cialties.
encouraged toreviewtheir workforce needs for
b. Legislation for Area Health Education Cengeneralists and subspecialists and to develop
ters should be modified and expanded to facilicurriculum and training opportunities commentate community-based primary care education
surate with those needs.
for medical students at every medical school.
15. To facilitate the expansion of ambulatory/
B. Graduate Medical Education
outpatient GME and to encourage innovative pro13. The number of Medicare and other funded gram development and growth, all approved GME
programs, including those based in community setfirst-year entry residency positions should be capped
at 10 percent more than the number of U.S. allopathic tings, should be eligible for Medicare direct and
indirect GME reimbursement.
and osteopathic medical school graduates.
16. Changes in the Medicare portion of GME
14. Financing strategies should suppon the goal
financing should be budget neutral. Savings in
that at least 50 percent of medical graduates should
complete a three-year residency program and enter direct and indirect GME from capping slots and
eliminating payments beyond the initial cenificageneralist practice and that the percentage who
choose subspecialties should concurrently decrease.
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
14
tion orfiveyears (with the previously noted excep21. Solutions must be found toreduceadministrative burdens in medical practice imposed by the
tions) should be directed to:
a. Training conducted in primary care ambula- third-party payers. These burdens are primary causes
of the increasing disillusionment among generalist
tory/community training sites.
physicians in practice.
b. Innovative programs to train generalist phy22. Tort reform must be implemented to resicians for rural and urban medically underserved
duce malpractice barriers to the provision of needed
areas.
primary care services, such as prenatal care.
c. Innovative programs to increase minoriiy
representation in the physician workforce pool. 23. Major incentives in Medicare and Medicaidreimbursementshould be implemented to en17. Financing strategies should support the goal
courage physicians to provide primary care serof increasing the percenuge ofresidencygraduates
vices to underserved rural and urban populations.
in the specialty fields of general surgery, adult and
These additional payments would assist in offsetchild psychiatry, and preventive medicine, and the
ting the heavy burden of unreimbursed care propercenuge of family physicians and general intervided by physicians in these settings.
. nists with additional geriatrics training. In addition
to the previously mentioned approaches:
24. Federal and Sute programs, including the
NHSC Scholarship and Loan Forgiveness Program,
a. Incentive salaries should be made available to
must be maintained, enhanced, and expanded to
residents who sign a contract indicating their
address therelativeundersupply of physicians in
intennon to complete their program in the above
rural and inner-city areas. Such programs should
fields, with a year-by-year payback for those
be maintained indefinitely in the most severe shonwho choose to train and practice in another
age areas that have little likelihood of attracting
specialty or subspecialty.
physicians.
b. Increased direct GME payments should be
25. Physicians in shortage areas are overworked,
allocated to general surgery programs that conisolated, and frequendy overwhelmed by the comtain an agreed-upon curriculum that specifiplex business of medicine. Systems of health care
cally prepares graduates for general surgical
practice, especially in rural and inner-city areas. delivery and professional support will enhance the
aaractiveness of practice in shortage areas.
c. Increased direct GME payments should be
allocated to adult and child psychiatry programs.
d. P—.ventive medicine residency training programs should receive Medicare GME reimbursements for the entire three-year period.
(Currendy, Medicare payments are made only
forresidents in their clinical training year, which
takes place only in thefirstyear.)
18. Primary care residency programs providing substantial training in urban or rural underserved
areas or serving a subsuntial percentage of medically underserved populations should be reimbursed
for generalistresidentsunder Medicare DME at a
higher rate.
C. Practice Environment
19. The economic incentives to enter generalist
fields must be increased and incentives to specialty
practice must bereducedby extending physician
paymentreformto include all third-party payers.
20. Partial loan forgiveness should be provided
for residents entering practice as family physicians,
general intemists, and general pediatricians.
�THIRD REPORT OF COGME • EXECUTIVE SUMMARY
15
ecific Recommendations for Medical Educators
1 he anainment of these workforce goals will
require a partnership between government
and the medical education system, which
comprises medical schools, hospitals, and other educational institutions and agencies. It will require
government to establish and implement a national
workforce plan with a set of goals, a rational education infrastructure, and a fuiancing mechanism, as
previously recommended. It will also require the
commitment and leadership of our Nation's medical educators. The following recommendations describe the Council's vision of a medical education
system thai is responsive to our Nation's physician
workforce needs in the 21st century.
T
Mission Statement and
Strategic Plan
a. The school establishes a minority recruitment/retention section with underrepresented minority participation, or individuals commiued to
the goals, and minority participation on the admissions committee.
b. Emphasis is placed on the development and
support of programs that improve the size and quality of the minoriiy applicant pool by focusing on
early intervention. The school participates in forums and networks involving students in high school,
elementary school, and primary levels, including
kindergarten, to expose minority youngsters to health
professions role models, encourage their interests
and pursuits in health, and provide networks of
mentoring programs to assist and support students
inclined toward health careers.
c. The school provides ongoing suppon to en26. The institution's mission statement recogsure the successful progress of these students through
nizes responsibility and accountability to societal
their educauon.
needs for more generalist physicians, more
underrepresented minority physicians, more primary Faculty Composition
care research, and the provision of more primary
30. The instimtion's departments and faculty
medical care, particularly to underserved urban and
composition are more balanced, with increased reprural communities.
resentation of generalist physicians, minority phy27. The strategic plan contains quantifiable outsicians, primary care researchers and physicians,
come measures for thes. societal needs, including
and other health care providers from communiiy
the percentage of:
settings.
a. graduates choosing generalist careers;
31. The institution's system of advancement
b. underrepresented minorities who apply and and tenure rewards faculty with demonstrated excellence in teaching in the same manner it recogmatriculate;
nizes excellence in biomedical research.
c. required educational experiences in commu32. The institution involves large numbers of
nity and underserved settings; and
community-based primary care physicians and other
d. graduates choosing to practice in underserved providers as preceptors, teachers, and role models
rural and urban areas.
for medical students andresidentsand gives significant academic recognition and adequate reimRecruitment, Admissions, and
bursement or other rewards (e.g., locum tenens covRetention Policies
erage for continuing medical education for their
28. The medical school's admissions policy,
contribution).
structure, and functionreflectthe need to recruit
and admit more students who are inclined to select Medical Education Objectives
the generalist disciplines of family practice, general
33. The institution incorporates effective adult
internal medicine, and general pediatrics.
education techniques in its curriculum. Self-di29. The medical school's admissions policies, rected learning and problem-solving directed skills
strucmre, and functionreflectthe need to recruit are emphasized throughout the curriculum for stuand admit more minority students in medical school. dents andresidentsto leant to acquire detailed information and to apply such knowledge effectively.
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
34. The institution emphasizes effective communication skills to improve the doctor/patient relationship.
35. The institution provides mandatory
multicultural awareness/sensitivity sessions for students, residents, and faculty.
Achieving a More Integrated
and Balanced Medical
Education Curriculum
36. The basic sciences are incorporated wiihin
a clinical context throughout the undergraduate curriculum.
37. Undergraduate and graduate training includes social, behavioral, and humanistic aspects of
health and health care delivery. Instruction is provided from faculty, researchers, and clinicians in
fields such as nursing, psychology, public health,
medical sociology, medical education, health services delivery, and bioethics.
38. Undergraduate and graduate training emphasizes the importance of team approaches to health
care delivery. They include experience working as
a team member with other health care professionals
and training in utilizing the skills and expertise of
physician assistants, nurse practitioners, nurses,
pharmacists, public health professionals, social
workers, and other health care professionals and
ancillary personnel.
39. Experimental primary care programs and
curricula are offered that may help reach 'he identified goals. Such models emphasize generalist practice and community-based training. The effecliveness and productivity of the fourth year of medical
school should be examined.
40. Undergraduate and graduate training contains well-defined curricula, educational objectives,
and evaluation methods, including outcome measures, to assess the effectiveness of the education
experience.
Expanding the Medical
Education Teaching
Environment
41. The curricula and clinical rotations provide
all students and residents with a balance between
hospital-based, subspecialty training and community-based, primary care training. A much greater
proportion of medical training is shifted io outpatient and community-based sites where lhe majority
of medical care is provided.
42. The community-based educational experiences are developed and managed with significant
16
community participation and involvement
43. Academic consortia are developed to link
together the various settings in which undergraduate and graduate medical education are provided,
including community hospitals, community health
centers. HMOs, and public health departments.
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
17
ckground, Charge, and Principles of COGME
lhe Council on Graduate Medical Education
(COGME) was authorized by Congress in
1986 to provide an ongoing assessment of
physician workforce trends and to recommend appropriate Federal and private sector efTorts to address identified needs. The legislation calls for
COGME to serve in an advisory capacity to the
Secretary of DHHS. the Senate Commiaees on Labor and Human Resources and Finance, and the
House of Representatives Commiuees on Energy
and Commerce and Ways and Means. By statute,
the Council terminates on September 30,1996.
T
cation programs and changes in the types of medical education training in graduate medical education programs.
5. Appropriate efforts to be carried out by
hospitals, schools of medicine, schools of osteopathy, and accrediting bodies with respect to the matters specified in (1), (2). and (3) above, including
effons for changes in undergraduate and graduate
medical education programs.
6. Deficiencies in, and needs for improvements in, existing data bases concerning the supply
and distribution of, and postgraduate training proThe legislation specifies that the Council is to
grams for, physicians in the United States and steps
comprise 17 members. Appointed individuals are
that should be taken to eliminate those deficiencies.
to include representatives of practicing primary care
The Council is to encourage entities providing GME
physicians, national and specialty physician organizations, international medical graduates, medical to conduct activities to voluntarily achieve the recommendations of this Coundl under (5) above.
student and house staff associations, schools of
medicine and osteopathy, public and private teach- Previous Reports
ing hospitals, health insurers, business, and labor.
The Council was asked by Congress to issue its
Federal representation includes the Assistant Secretary for Health, DHHS; the Administrator of the firstreponby July 1,1988. and subsequent reports
Health Care Finandng Administration, DHHS; and every three years. Since its establishment, COGME
the Chief Medical Director of the Veterans Admin- has submitted the following reports to Congress:
istration.
• First Repon of the Council, Volume I and
Volume D 0988).
Charge to the Council
Although called the Council on Graduate Medical Education, the charge to COGME is much
broader. Title VII of the Public Health Service Act
in Section 799(H), as amended by Public Law 99272, requires that COGME provides advice and
makes recommendations to the Secretary and Congress on the following:
• Second Report: The Financial Status of Teaching Hospitals and the Underrepresentation of Minorities in Medicine 0990).
• Addendum to the Second Report The Financial Status of Veterans Administration Teaching
Hospitals 0990).
• Scholar in Residence Report: Refonn in
1. The supply and distribution of physicians in Medical Education and Medical Education in the
Ambulatory Setting 0991).
the United States.
2. Current and future shortages or excesses of Principles of the Council
physicians in medical and surgical specialties and
In making these recommendations to Congress
subspecialties.
and the Secretary, the Council's deliberations have
3. Issues relating to foreign medical school
been guided by the following prindples:
graduates.
• The primary concern of the Council must be
4. Appropriate Federal policies withrespectto the health of the American people. There must be
the matters specified in (1), (2), and (3) above,
ensured access to quality health care for all. Conincluding policies concerning changes in the ficern for the well-being of the health professions,
nancing of undergraduate and graduate medical edu- medical schools, and teaching hospitals, while im-
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
ponant, must be secondary to the previously mentioned concerns.
18
Issues for Further Exploration
The Councilrecognizesthat there are a number
• The Council should consider the diverse needs of issues requiring further exploration. Among
ofthe various geographic areas and segments ofthe these are the following:
population, such as rural and inner-city areas and
• The Nation's voluntary system of specialty
minority and disadvantaged populations.
certification, medical education accreditation, and
• A goal of the Council is increased representa- licensure, which have a significant impact on phytion of minorities in the health professions. Tar- sician workforce supply and distribution.
geted programs are appropriate and a necessary
• The important role of physician assistants,
means of achieving this objective.
nurse practitioners, and certified nurse midwives in
• The Council must consider the interrelation- delivering primary care, when working in collaboship between services provided by physicians and ration with generalist physicians.
those provided by other health professions.
• Representation of women in medicine, par• Although the Council supports the continua- ticularly in academic roles.
tion of successful private sector initiadves, it recog• The State's role, including model initiatives,
nizes that an active Federal and State role has been
in addressing workforce data needs, supply, and
and will continue to be needed to address the spedistribution.
cific problems of distribution, quality, and access to
• Otherfinancingand infrastructure approaches
healthcare.
that have potential to attain the stated workforce
• The Council should be concerned about efgoals.
fects on total health care costs in the Nation. The
Council must consider thefinancialand programmade impact of its recommendations on the Federal budget, both short and long term.
• The Council recognizes that health care in the
United States is not a closed system; therefore, its
deliberations must be guided by an international
perspecuve.
• The Council must consider changes in demographics (e.g., the aging population), disease patterns (e.g., increasing prevalence of the acquired
immunodeficiency syndrome [AIDS]), patterns of
health care delivery (e.g., increased emphasis on
ambulatory care), and the unmet needs for prevention and care.
• The Council believes that a strong system of
medica] education must be maintained in order to
expand medical knowledge and provide access to
quality medical care through an adequate supply of
appropriately educated physicians.
• American medical education should provide a
basis for physicians of the future to be able to deliver continually improving patient care through a
better understanding of disease processes and their
clinical manifestations. The education system
should prepare physicians to appropriately apply
new techniques of diagnosis, treaunent, and prevention in a compassionate and cost-effective manner.
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
19
OGME Members, Subcommittees, and Staff
Members
David Satcher, M.D Ph.D., Chairperson
Presideni, Meharry Medical College
Nashville, Tennessee
M
Stuart J. Marylander, Vice Chairperson
President and Chief Executive Officer
Triad Healthcare
Encino, California
Paul C. Brucker, MD.
President, Thomas Jefferson University
Philadelphia, Pennsylvania
Jack W. Colwill, M.D.
Professor and Chairman, Department of Family
and Community Medicine
University of Missouri-Columbia
Columbia, Missouri
Lawrence U. Haspcl, D.O.
Executive Vice President, Hospital Operations
Chicago College of Osteopathic Medicine
Chicago, Illinois
WilliamS. Hoffman, Ph.D.
Director. UAW Social Security Department
Detroit, Michigan
Pedro Ruiz, M.D.
Professor, Department of Psychiatry
Baylor University College of Medicine
Houston, Texas
Juereta P. Smith, R.N., J.D.
Associate Counsel
Corporate Counsel, USAA
San Antonio, Texas
Margaret T. Stanley, M.H.A.
Administrator
Washington State Health Care Authority
Olympia, Washington
Robert L. Summiti, M.D.
Dean, College of Medicine
University of Tennessee
Memphis. Tennessee
EricE.Whitaker, M.P.H.
Past President, American Medical Student
Association
Medical Student, University of Chicago
Pritzker School of Medicine
Chicago, Illinois
ModenaH. Wilson, MD.
Director, Division of General Pediatrics and
Adolescent Medicine
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Charles E Windsor
President and Chief Executive Officer
SLM-ry's Hospital
East . Louis, Illinois
George D. Zuidema, MD.
Vice Provost for Medical Affairs
The University of Michigan
Ann Arbor. Michigan
Fitzhugh Mullan, MD.
Director, Bureau of Health Professions
Health Resources and Services Administration
Public Health Service
Rockville, Maryland
Robert G.Eaton
Associate Administrator for
Program Development
Health Care Financing Administration
Washington, DC
Elizabeth M. Short, MD.
Associate Chief Medical Director
for Academic Affairs
Department of Veterans Affairs
Washington, DC
�THIRD REPORT OF COGME - EXECUTIVE SUMMARY
20
Council Subcommittees-
Staff
Physician Manpower Subcommittee
Marc L. Rivo, M D , M J J I , Executive Secretary
Director. Division of Medicine
George D. Zuidema, MD., Chairperson
Jack M. Colwill. MD.
WilliamS. Hoffman, PhD.
Fitzhugh Mullan, MD. (ASH)
Pedro Ruiz. MD.
Juereta P. Smith, R.N., JD.
ModenaH. Wilson, MD.
Charles E Windsor
Staff Liaison:
Jerald M. KatzofT, Division of Medicine
Medical Education Programs and
Finandng Subcommittee
Lawrence U. Haspel, D.O., Chairperson
Paul C. Bracker, M D .
Robert G. Eaton (HCFA)
Stuart J. Marylander
Elizabeth M. Short, MD. (VA)
Margaret T. Stanley, M.H.A.
Robert L. Summiti, MD.
EricEWhitaker.MJUL
Staff Liaison:
Debbie M. Jackson, M.A.,
Division of Medicine
Minority Representation in Medidne
Subcommittee
Juereta P. Smith, R.N,JD, Chairperson
Jack M. Colwill, MD.
William S. Hoffman, PhD.
Stuart J. Marylander
Pedro Ruiz, MD.
Robert L. Summia, M.D.
EricEWhiiaker.M.P.H.
Staff Liaison:
Lanardo E. Moody, M.A.,
Division of Medicine
Carol S.Gldch, PhD.
Chief, Spedal Projects and Data Analysis Branch
F. Lawrence Clare, M D , M.P.H.
Deputy Executive Secretary
Chief, Data Analysis Section
Jerald M. Katzoff
Staff Liaison, Physician Manpower Subcommittee
Debbie M. Jackson, MA.
Staff Liaison, Medical Education Programs and
Financing Subcommittee
Lanardo E Moody, M.A.
Staff Liaison, Minority Representation in Medicine Subcommittee
Eva M. Stone
Committee Management Assistant
Susan S. Sumner
Secretary
�COUNCIL ON GRADUATE MEDICAL EDUCATION
Third Report
Improving Access to Health Care
Through Physician Workforce Reform:
Directions for the 21st Century
• Changing the Physician Supply
Increasing Minority Representation in Medicine
' Reforming Medical Education
October 1992
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
Health Resources and Services Administration
— ^ ^ ^
'
, U
JMBUHIHIMLHUmilj
�iii
THIRD REPORT OF COGME
Table of Contents
List of Figures and Tables
Highlights
Charge to the Council
Previous Reports
Principles of the Council
Findings
Goals
Recommendations for the Nation
Specific Recommendations for Medical Educators
Issues for Further Exploration
COGME Members, Subcommittees, and Staff
COGME Members
Subcommittees
Staff
vu
vii
vii
vii
viii
viii
ix
ix
ix
x
x
xi
xi
I. Introduction: The Crises in Health Care Delivery and
Physician Workforce Supply
The Crisis in Health Care Delivery
Inadequate Access to Health Care
Poor and/or Unequal Health Status Within the Population
The High Cost of Health Care
The Crisis in Physician Workforce Supply
References
1
1
2
3
4
5
II. Findings of COGME
Finding No. 1
Finding No. 2
Finding No. 3
Minorities Enter U.S. Medical Schools
Predominately Minority Medical Schools Are Founded
Civil Rights and Minority Medical Students
Minority Medical Students in the 1980s and 1990s
Academic Preparadon of Underrepresented Minorities
Matriculation and Retention Rates of Underrepresented Minority Students
Current Status
Today's African American Men and Medical Education
Shortage of Minority Medical School Faculty
Minority Community Has Insufficient Supply of Physicians
The Need for More Minorities in Medicine
Finding No. 4
General Surgery
Adult and Child Psychiatry
Preventive Medicine
Geriatrics
7
10
13
14
14
15
15
16
16
17
17
18
18
19
22
22
23
24
24
�THIRD REPORT OF COGME
Finding No. 5
Finding No. 6
Institutional Mission Statement
Institutional Strategic Plan
Recruitment, Admissions, and Retention Policies
Faculty Composition and Reward System
Medical Education Objectives
Medical Education Curricula
Expanding the Medical Education Teaching Environment
Academic Consortia
Area Health Education Centers
References
HI. Finding No. 7: Barriers to Change—New Directions
Finding No. 7
Absence of a National Physician Workforce Plan and System
Lack of Consensus on Who Delivers Primary Medical Care
Reimbursement System Disincentives
Biomedical Research and Subspecialty-Oriented Medical Education System
Disincentives in the Accreditation, Licensure, and Certification Systems
GME Financing System and Disincentives
State Initiatives in GME Financing and Allocation of Residency Positions
References
IV. Findings, Goals, and Recommendations
25
28
28
29
29
29
30
31
31
32
33
34
43
43
43
46
47
47
48
49
54
56
59
Findings and Goals
Recommendations for the Nation
National Physician Workforce Goals
Physician Workforce Infrastructure
Financing the Physician Workforce Plan
Specific Recommendations for Medical Educators
Mission Statement and Strategic Plan
Recruitment, Admissions, and Retention Policies
Faculty Composition
Medical Education Objectives
Achieving a More Integrated and Balanced Medical Education Curriculum
Expanding the Medical Education Teaching Environment
59
60
60
60
61
63
64
64
64
64
64
65
Appendix: Assumptions of Illustrative Modeling Scenarios of Physician
Supply Projections to Conform to COGME's Goals
67
Projections of Present Trends
Goal-Oriented Supply Projections
Assumptions for the Aggregate Supply Projections
Assumptions for the M.D. Specialty Supply Projections
Assumption for the D.O. Specialty Supply Projections
Results of the Goal-Oriented Aggregate Supply Projections
Alternative Measures of Physician Supply—Full-Time Equivalent Physicians
Results of the Goal-Oriented Specialty Mix Supply Projections
67
67
67
67
68
68
69
69
�iv '
•
THIRD REPORT OF CO
List of Figures and Tables
1.
Age-Adjusted Selected Indicators of Health Status and Medical Care Utilization,
by Race and Poverty Status, 1986.
2.
Infant Mortality by Selected Country, 1987.
2
'
3
3. Life Expectancy at Birth in Selected OECD Countries, 1987.
3
4.
Per Capita Health Spending, 1989.
4
5.
Total Health Expendimres as a Percent of Gross Domestic Product:
Selected OECD Countries, 1970-1989.
4
6.
A Steady Decrease in Primary Care M.D.s Compared to Other Specialties: 1931-1988
8
7.
Generalists as a Percentage of Physicians: Selected Nations, Early 1980s.
Number of Health Professions Shortage Areas (HPSA) and Number of Physicians
Needed to Remove HPSA Designation.
9. Non-Federal Primary Care Physicians (M.D. & D.O.), by County Size, 1988.
10. Ratio of Physicians Per 100,000 Population by Nonmetropolitan and Metropolitan
Location and Primary Care Specialty.
10
8.
11. Percent of Physicians in Each Primary Care Specialty and Percent of U.S. Population
by Nonmetropolitan and Metropolitan Location, 1989.
11
11
12
12
12. Underrepresented Minorities (URMs) as a Percent of the U.S. Population
and Medical School Matriculants: 1970-1990.
13. Extent to Which Minority Physicians Practiced in HMSAs.
15
21
14. Percent of Physicians Graduating From U.S. Medical Schools
1976-1985 Pracucing in Rural Counties in 1991 by Specialty.
23
15. Supply of Acuve Physicians (M.D. & D.O.) and Ratio to Population.
26
16. Projected Supply of International Medical Graduates (IMG).
26
17. Income of U.S. Physicians - Percent if Average Physician Income for
General Family Practice, Internal Medicine, and Pediatrics.
47
18. U.S. Medical School Faculty - Number of Full-time Faculty by Department.
48
19. Osteopathic Schools of Medicine - Full-time Faculty by Discipline, 1990-1991.
48
20. Growth in the M.D. and D.O. Physician Supply.
68
21. Physician Supply in 2020 (Basic).
68
22. Physician Supply in 2020 (COGME).
68
23. U.S. Medical School Class of 2000 PGY-1 Residents: Basic.
69
24. U.S. Medical School Class of 2000 Graduate Year 10: Basic.
70
25. U.S. Medical School Class of 2000 PGY-1 Residents: COGME Goal Oriented.
70
26. U.S. Medical School Class of 2000 Graduate Year 10: COGME Goal Oriented.
70
Tables
1.
2.
•
Medicare Expenditures for Direct and Indirect Medical Education, Fiscal Years 1984-1992 51
Medicare Expendimres for Indirect Medical Education, Fiscal Years 1984-1992
52
�vii
THIRD REPORT OF COGME
HIGHLIGHTS
^he Council on Graduate Medical Education
(COGME) was audiorized by Congress in
1986 to provide an ongoing assessment of
physician workforce trends and to recommend appropriate Federal and private sector efforts to address identified needs. The legislation calls for
COGME to serve in an advisory capacity to the
Secretary of the Department of Health and Human
Services (DHHS), the Senate Committees on Labor
and Human Resources and Finance, and the House
of Representatives Committees on Energy and Commerce and Ways and Means. By statute, the Council terminates on September 30, 1996.
T
The legislation specifies that the Council is to
comprise 17 members. Appointed individuals are
to include representatives of practicing primary care
physicians, national and specialty physician organizations, international medical graduates, medical
student and house staff associations, schools of
medicine and osteopathy, public and private teaching hospitals, health insurers, business, and labor.
Federal representation includes the Assistant Secretary for Health, DHHS; the Administrator of the
Health Care Financing Administration, DHHS; and
the Chief Medical Director of the Veterans Administration.
Charge to the Council
Although called the Council on Graduate Medical Education, the charge to COGME is much
broader. Title VII of the Public Health Service Act
in Section 799(H), as amended by Public Law 99272, requires that COGME provides advice and
makes recommendations to the Secretary and Congress on the following:
1. The supply and distribution of physicians in
the United States.
2. Current and future shortages or excesses of
physicians in medical and surgical specialties and
subspecialties.
3. Issues relating to foreign medical school
graduates.
4. Appropriate Federa] policies with respect to
the matters specified in (1), (2), and (3) above,
including policies concerning changes in the f i nancing of undergraduate and graduate medical education programs and changes in the types of medi-
cal education training in graduate medical education programs.
5. Appropriate efforts to be carried out by hospitals, schools of medicine, schools of osteopathy,
and accrediting bodies with respect to the matters
specified in (1), (2), and (3) above, including efforts for changes in undergraduate and graduate
medical education programs.
6. Deficiencies in, and needs for improvements
in, existing data bases concerning the supply and
dismbution of, and postgraduate training programs
for, physicians in the United States and steps that
should be taken to eliminate those deficiencies.
The Council is to encourage entities providing graduate medica] education to conduct activities to voluntarily achieve the recommendations of this Council under (5) above.
Previous Reports
The Council was asked by Congress to issue its
first report by July 1, 1988, and subsequent reports
every three years. Since its establishment, COGME
has submitted the following reports to Congress:
• First Report of the Council, Volume I and
Volume D (1988).
• Second Report: The Financial Status of Teaching Hospitals and the Underrepresentation of Minorities in Medicine (1990).
• Addendum to the Second Repon: The Financial Status of Veterans Administration Teaching
Hospitals 0990).
• Scholar in Residence Report: Refonn in
Medical Education and Medical Education in the
Ambulatory Setting (1991).
Principles of the Council
In making these recommendations to Congress
and the Secretary, the Council's deliberations have
been guided by the following principles:
• The primary concern of the Council must be
the health of the American people. There must be
ensured access to quality health care for all. Concern for the well-being of the health professions,
medical schools, and teaching hospitals, while important, must be secondary to the previously mentioned concerns.
�• The Council should consider the diverse needs
of the various geographic areas and segments of the
population, such as rural and inner-city areas and
minority and disadvantaged populadons.
• A goal of the Council is increased representauon of minorities in the health professions. Targeted programs are appropriate and a necessary
means of achieving this objective.
• The Council must consider the interrelationship between services provided by physicians and
those provided by other health professions.
• Although the Council supports the continuation of successful private sector initiatives, it recognizes that an active Federal and State role has been
and will continue to be needed to address the specific problems of distribution, quality, and access to
health care.
• The Council should be concerned about effects on total health care costs in the Nation. The
Council must also consider the financial and programmatic impact of its recommendations on the
Federal budget, both short and long term.
• The Council recognizes that health care in the
United States is not a closed system; therefore, its
deliberations must be guided by an international
perspective.
• The Council must consider changes in demographics (e.g., the aging population), disease patterns (e.g., increasing prevalence of the acquired
immunodeficiency syndrome [AIDS]), panems of
health care delivery (e.g., increased emphasis on
ambulatory care), and the unmet needs for prevention and care.
• The Council believes that a strong system of
medical education must be maintained in order to
expand medical knowledge and provide access to
quality medical care through an adequate supply of
appropriately educated physicians.
• American medical education should provide
a basis for physicians of the future to be able to
deliver continually improving patient care through
a better understanding of disease processes and
their clinical manifestations. The education system
should prepare physicians to appropriately apply
new techniques of diagnosis, treatment, and prevention in a compassionate and cost-effective manner.
Findings
reimbursement systems, which hinder health care
access. The Council's findings conclude that the
Nation has:
• Too few generalists (i.e., family physi,
general intemists, and general pediatricians) anc
too many nonprimary care specialists and
subspecialists.
• Access to care problems in inner-city and
rural areas that are growing despite substantial increases in the total physician supply.
• Too few underrepresented minority physicians.
• Shortages in certain nonprimary care medical
specialties, including general surgery, adult and chile
psychiatry, and preventive medicine, and amonj
generalist physicians with additional geriatrics training.
• An increasing physician-to-population ratio
which will do little to improve the public's healtl
or increase access and will hinder cost-containmen
efforts.
• A system of undergraduate and graduate edu
cation that can be more responsive to these regiona
and national workforce needs.
• No national physician workforce plan or —'
ficient incentives in medical education fin;
and health care reimbursement to attain the a,^
priate specialty mix, racial/ethnic composition, anc
geographic distribution of physicians.
Goals
Based on thesefindings,COGME recommend
adoption of the following national physiciai
workforce goals. The United States should:
• Move toward a system in which 50 percent ol
physicians practice in the generalist disciplines oi
family medicine, general internal medicine, and
general pediatrics.
• Increase to at least 50 percent the percentage
of residents who complete a three-year traininf
program in family medicine, general internal medicine, and general pediatrics and enter generalisi
practices.
• Improve physician distribution to eliminatf
primary medical care shortage areas and urban
rural disparities.
• Double the number of entering
underrepresented minority medical students
1,500 to 3,000 by the year 2000, a goal estat
by the Association of American Medical Collc^-o.
c
The Council's seven major findings identify a
series of deficiencies in the current physician supply, medical education financing, and health care
�ix
THIRD REPORT OF COGME
VIII
• Increase the number of general surgeons, preventive medicine specialists, adult and child psychiatrists, and general intemists and family physicians with addiuonal geriatrics training.
• Maintain the osteopathic and allopathic physician-to-populauon rado at current levels.
Recommendations for the
Nation
The centerpiece of COGME's recommendauons is the establishment of a national physician
workforce plan, rational medical education infrastructure, and financing strategy to attain the nauonal physician workforce goals. Recommendations include:
• Establishing a National Physician Workforce
Commission and State Commissions to determine
local, regional, and national needs.
• Implementing the workforce plan through
local. State, or regional academic consortia, which
might include one or more medical schools, teaching and community hospitals, health maintenance
organizations (HMOs), community health centers,
and other educational and teaching institutions or
agencies.
• Allocating residency positions and graduate
medical education (GME) funding based on State
and regional workforce needs and national goals
for aggregate physician supply, minority recruitment and retention, and specialty distribution.
• Encouraging allopathic and osteopathic medical schools to not increase enrollment.
1
mend
siciar.
!
I
:ent of
nes of
and
:ntage
ainin?
medi-'
eralisj
ninate
jrbanj'
leges
• Capping Medicare (and other) funded firstyear residency positions at 10 percent more than the
number of U.S. allopathic and osteopathic medical
graduates.
• Providing undergraduatefinancialincentives,
including loan and scholarship programs, to recruit
and retain more underrepresented minorities and
graduate more generalists.
• Providing GME financial incentives, through
Medicare and other payers, to train more generalists and fewer nonprimary care specialists and
subspecialists.
• Increasing incentives for primary care practice and service in inner-city and rural areas, through
physician payment reform, reduction of administrative burdens. National Health Service Corps
(NHSC) scholarship and loan programs, tort reform, and differential Medicare and Medicaid reimbursement for practice in shortage areas.
Specific Recommendations for
Medical Educators
A physician workforce plan and financing strategy will help our Nation respond to societal needs
for more minority and generalists physicians and
for access to more primary care services, particularly in underserved inner-city and rural areas.
Achieving these national workforce goals will also
require the commitment and leadership of our
Nation's medica] educators. The Council's vision
of a medical education system that is responsive to
our Nation's health care needs in the 21st century
will be reflected in the institution's:
• Mission statement and strategic plan.
• Recruitment, admissions, and retention
policies.
• Medica] education objectives and curricula.
• Faculty composition and reward system.
• Medical education and teaching environment.
• Linkages with a variety of teaching sites.
Issues for Further Exploration
The Council recognizes that there are a number
of issues requiring further exploration. Among
these are the following:
• The Nation's voluntary system of specialty
certification, medical education accreditation, and
licensure, which have a significant impact on physician workforce supply and distribution.
• The important role of physician assistants,
nurse practitioners, and certified nurse midwives in
delivering primary medical care.
• Representation of women in medicine, particularly in academic roles.
• The State's role, including model initiatives,
in addressing workforce data needs, supply, and
distribution.
• Other financing and infrastructure approaches
that have potential to attain the stated workforce
goals.
�C O G M E Members,
Subcommittees, and Staff
C O G M E Members
Adolescent Medicine
The Johns Hopkins University School of Medicine
Baltimore, Maryland
David Satcher, M.D., Ph.D., Chairperson
President, Meharry Medical College
Nashville, Tennessee
Charles E. Windsor
President and Chief Executive Officer
St. Mary's Hospital
East St. Louis, Illinois
Stuart J . Marylander, Vice Chairperson
President and Chief Executive Officer
Triad Healthcare
Encino, Califomia
George D. Zuidema, M.D.
Vice Provost for Medical Affairs
The University of Michigan
Ann Arbor, Michigan
Paul C. Brucker, M.D.
President, Thomas Jefferson University
Philadelphia, Pennsylvania
Fitzhugh Mullan. M.D.
Director, Bureau of Health Professions
Health Resources and Services Administration
Public Health Service
Rockville, Maryland
Jack W. Colwill, M.D.
Professor and Chairman, Department of Family
and Community Medicine
University of Missouri-Columbia
Columbia, Missouri
Lawrence U. Haspel, D.O.
Executive Vice President, Hospital Operations
Chicago College of Osteopathic Medicine
Chicago. Illinois
William S. Hoffman, Ph.D.
Director, UAW Social Security Department
Detroit, Michigan
Pedro Ruiz, M.D.
Professor, Department of Psychiatry
Baylor University College of Medicine
Houston, Texas
Juereta P. Smith, R.N., J.D.
Associate Counsel
Corporate Counsel, USAA
San Antonio, Texas
Margaret T. Stanley, M.H.A.
Administrator
Washington State Health Care Authority
Olympia, Washington
Robert L. Summitt, M.D.
Dean, College of Medicine
University of Tennessee
Memphis, Tennessee
Eric E. Whitaker, M.P.H.
Past President, American Medical Student
Association
Medical Student, University of Chicago
Pritzker School of Medicine
Chicago, Illinois
Modena H. Wilson, M.D.
Director, Division of General Pediatrics and
Roben G. Eaton
Associate Administrator for
Program Development
Health Care Financing Administration
Washington, DC
Elizabeth M. Short, M.D.
Associate Chief Medical Director
for Academic Affairs
Department of Veterans Affairs
Washington, DC
�THIRD REPORT OF COGME
XI
Subcommittees
Staff
Physician Manpower Subcommittee
Marc L. Rivo, M.D., M.P.H.
Executive Secretary
Director, Division of Medicine
George D. Zuidema, M.D., Chairperson
Jack M. Colwill, M.D.
William S. Hoffman, Ph.D.
Fitzhugh Mullan, M.D. (ASH)
Pedro Ruiz, M.D.
Juereta P. Smith, R.N., J.D.
Modena H. Wilson, M.D.
Charles E. Windsor
Staff Liaison:
Jerald M. Katzoff, Division of Medicine
Medical Education Programs and
Financing Subcommittee
Lawrence U. Haspel, D.O., Chairperson
Paul C. Brucker, M.D.
Roben G. Eaton (HCFA)
Stuan J. Marylander
Elizabeth M. Shon, M.D. (VA)
Margaret T. Stanley, M.H.A.
Roben L. Summitt, M.D.
Eric E. Whitaker, M.P.H.
Staff Liaison:
Debbie M. Jackson, M.A.,
Division of Medicine
Minority Representation in Medicine
Subcommittee
Juereta P. Smith, R.N., J J)., Chairperson
Jack M. Colwill, M.D.
William S. Hoffman, Ph.D.
Stuan J. Marylander
Pedro Ruiz, M.D.
Roben L. Summitt, M.D.
Eric E. Whitaker, M.P.H.
Staff Liaison:
Lanardo E. Moody, M.A.,
Division of Medicine
Carol S. Gleich, Ph.D.
Chief, Special Projects and Data Analysis Branch
F. Lawrence Clare, M.D., M.P.H.
Deputy Executive Secretary
Chief, Data Analysis Section
Jerald M. Katzoff
Staff Liaison, Physician Manpower Subcommittee
Debbie M. Jackson, M.A.
Staff Liaison, Medical Education Programs and
Financing Subcommittee
Lanardo E. Moody, M.A.
Staff Liaison, Minority Representation in Medicine Subcommittee
Eva M. Stone
Committee Management Assistant
Susan S. Sumner
Secretary
�THIRD REPORT OF COGME
HAPTER I - Introduction: The Crises in Health
are Delivery and Physician Workforce Supply
m
I
n 1988, when COGME issued its first report to
the Secretary and Congress, it expressed concern that physician specialty and geographic
maldistribution was growing despite an increasing
aggregate supply of physicians. At that time, concerns about access to health care and rising health
care costs had not yet been so prominendy thrust
into the national spotlight. Similarly, physician
workforce policy was not high on the national
agenda.
The historical context of this report is vastly
different. Today, the health care system is acknowledged to be in crisis. While health care expenditures exceeded $650 billion in 1990 and are
projected to reach $1 trillion in 1995, 37 million
Americans remain medically uninsured, and millions more face barriers to basic health care. Furthermore, the Nation's basic health status indicators, which are in some measure influenced by
access to health care, lag behind most economically
developed countries. There is now recognition that
health care reform to ensure access to basic care for
all Americans is not possible without physician
workforce reform. It is in this context that COGME
has been examining physician workforce supply
and distribution and its impact on ensuring access
to care for all Americans.
The Crisis in Health Care
Delivery
Within the community of nations, the United
States leads in biomedical research, technology development, and some aspects of health care delivery. The United States produces excellent physicians and leads in the development, application,
and diffusion of new technologies for disease diagnosis and treatment. The United States also is
recognized for innovations in health care delivery
systems such as HMOs and other managed care
systems.
1
Nevertheless, the health care system has notable flaws. Although the United States spends far
more per capita on health care than any other nation, millions of Americans face significant barriers
trying to obtain basic health services. The United
States pioneers in biomedical research and sophisticated medical technology, funded through the National Institutes of Health (NIH), but basic health
status indicators lag far behind other developed
countries. Although the Centers for Disease Control has led advances in epidemiology and disease
prevention and control, the actual performance of
the health care system in providing basic screening,
counseling, and immunization services is considered to be far below target levels.
2
Today, public concern about the health care
crisis is expressed through the sheer number of
national health care reform proposals that have been
introduced. The major elements of the health care
crisis include:
• Inadequate access to care.
• Poor and/or unequal health status within the
population.
• The high cost of health care.
Inadequate Access to Health Care
The problems associated with access to healu
care have deeply rooted social, economic, and educational implications. Significant numbers of people
do not have access to affordable and quality health
care, and the numbers continue to increase. Availability of insurance or other third-party coverage is
a necessary means of access for preventive and
medical services. Yet, 37 million Americans lack
health insurance, three-fourths of them are fulltime workers and their families, and another 16
million have inadequate coverage. In 1990, 17
percent of the nonelderly U.S. population did not
have private or public coverage. In 1988, twothirds of the uninsured population were in families
of full-year steadily employed workers. These
individuals and their families face barriers in obtaining medical care and are less likely to get preventive care or adequate care when faced with serious illness.
3
4
Studies have shown that lack of insurance coverage is the major barrier to health care. Without
insurance coverage, many individuals and their families forgo medical care or opt for reduced care. One
recent study showed data indicating that lack '
access to basic care in Washington, D.C, and i
United States resulted in excess needless prematurt
deaths among African Americans from common
treatable conditions such as asthma, pneumonia.
�THIRD REPORT OF COGME
Fig. 1 - Age-Adjusted Selected Indicators of Health Status and Medical Care Utilization,
by Race and Poverty Status, 1986
Indicator and poverty status
White
Black
Hispanic
Acute conditions (per 1,000)
Nonpoor
Poor
Difference*
2083
2342
259
1204
1514
310
1651
1745
94
Restricted Activity Days (per person)
Nonpoor
Poor
Difference
14.3
26.6
12J
15.5
26.6
11.1
14.6
16.5
1.9
Fair or Poor Health (percent)
Nonpoor
Poor
Difference
•7.7*
20.2%
12^%
135%
25.8%
123%
105%
24.7%
14.2%
Physician Contacts (per person)
Nonpoor
Poor
Difference
Hospitalization (percent)
Nonpoor
Poor
Difference
5.6
73
1-7
8.3%
12.1 %
3.8 %
7.6
6.2
-1.4
7.1 %
14.6%
75%
4.4
4.7
0.3
7.6%
10.7 %
3.1 %
* Poor - Nonpoor. Tht NH1S defines an acute condition as a heal* condinon that caused arcstricoonin activityOTphysician contact in the pet two weeks.
Persons were classified as poor if their (amity tDcome was below the official poveny threshold.
Source: National Center for Health Statistics. National Health Interview Survey. 1986.
5
hypertension, and tuberculosis. Similarly, studies
in New York City indicate that residents in lowincome census tracts were significantly more likely
to be hospitalized for common conditions that can
be treated with access to basic health care.
6
Poor and/or Unequal Health Status Within
the Population
Many socioeconomic factors affect health status, including poverty, unemployment, lack of educauon, poor housing, and unsafe neighborhoods.
Figure 1 displays indicators of health status and
medical care utilization by race and poverty status.
This information provides evidence that the health
status of individuals in the population varies according to race and socioeconomic status. Simply
stated, our Nation's most vulnerable citizens—minorities, the poor, the unemployed, and the poorly
educated—are at greatest risk for poor health.
However, health problems are exacerbated by
barriers to regular primary and preventive care.
Unfortunately, our Nation's most vulnerable citizens are also the mostly likely to be uninsured.
Although Medicaid is often considered to be the
catchall program for the poor, in reality, this is no ;
the case. At the time it was enacted as Title XIX oi
the Social Security Act in 1965, Medicaid was na i
intended to pay for medical services of all poa ±
Americans. Instead, it was designed to provide 3
medical assistance to those in the welfare program
categories of the aged, blind and disabled, and pooi ?
women or families with children, thus leaving oui \
poverty-stricken single people and childless couples. *
The restricted financial criteria for Medicaid eligi- i
bility have excluded the employed poor. For rea- \
sons that include these limitations on eligibility. \
about 60 percent of the poor do not receive Medic- jj
aid benefits. This leaves a significant gap between I
the number of people living below the poverty level ^
and the actual number of Medicaidrecipients.Con- i
sequendy, substantial numbers of individuals do ?
not benefit from any health program coverage for ?
major portions of the year. The resulting lack of i health care is associated with worse health status £
among the poor.
|
7
International comparisons also provide much *
ammunition for critics of the U.S. health care system. The United States fares poorly as compared ^
�THIRD REPORT OF COGME
with other developed countries in several major
health indices:
• In 1988, the United States ranked 23rd out of
40 selected countries in terms of infant mortality
(see figure 2 for U.S. comparison of infant mortality among five selected countries belonging to the
Organization for Economic Cooperation and Development [OECD]).
8
• The United States ranks in the bottom half
among the OECD countries in terms of male and
female life expectancy at birth (figure 3).
9
The High Cost of Health Care
10
Policymakers agree that strategies to expand
access and control costs must proceed together. To
pursue one goal without the other is to further undermine a system already under serious stress. The
Fig. 2 - Infant Mortality by Selected Country, 1987
10.1
9.8
10 S
6
OECD Average
7£
7J3
8
9.1
S2
persistent and substantial increases in the cost:
health care continue to alarm economists, electee
officials, business, labor, and the public. Expenditures in the health care system are growing at a rate
that is regarded as unsustainable by both private
and public payers. Health care expenditures are
estimated to exceed $1 trillion in 1995 and $1.8
trillion in the year 2000. In every year from 1950 to
1985 except three (1973, 1978, 1984), the inflation
in nationa] spending for health care outpaced the
rest of the economy. Put differently, in 1950 the
United States spent about $1 billion per month in
health care; by 1985 it was spending more than $1
billion per day.
When compared with other industrialized nations, the United States spends significantly more
of its gross domestic product (GDP) for health care.
Furthermore, health care costs continue to escalate
to the detriment and sacrifice of other national goals.
The per capita spending for the United States is 40
percent higher than Canada, 90 percent higher than
Germany, and 127 percent higher than Japan (figure 4). Perhaps even more troubling is the continued increase in percentage of GDP in the United
States through 1989, when the percentages for other
industrialized countries appear to have stabiliz
since the early 1980s (figure 5).
11
-
£
2 Canada
France
Germany
United
Kingdom
Italy
U.S.
Source: Heam United Stares. 7990. NCHS 1991.
Fig. 3 - Life Expectancy at Birth in Selected OECD Countries, 1987
81.1
O E C D Female A v g 78.6
- - O E C D Uate A v g 72.1
r
I Male
78.9
78.4
7£9
72.7
72.6
Canada
France
;
11
Germany
S<xra Heann. UntedSuies. 1990. NCHS. 1991
ttaty
71A
United
Kingdom
I
A comparauve analysis of the health care costs
in selected countries reveals key features that distinguish the United States from other nations in
providing health care services. Compared with
other countries, many more physicians in the United
States choose to practice in highly focused medical
specialties and subspecialties. Studies suggest that
the cost of physician services is much greater in the
United States and that patients undergo more intense medical services per visit because of the exceptionally high proportion of nonprimary care specialists in this country.
12
Considering the staggering health care costs
that continue to escalate, it is no wonder why health
care issues command frontline national attention.
Despite all the billions spent on health care and the
remarkable increase in expenditures for biomedical
research, new technology, and medical care, the
United States has a rather dismal health status
scorecard due to its failure to provide routine, ongoing primary care to surprisingly large segments
of its population.
�THIRD REPORT OF COGME
Fig. 4 - Per Capita Health Spending, 1989
Percent by Which U.S. Exceeds
Per Capita Expencfitures In Dollars
S2£S4 i
U.S.
Canada
Switzerland
Sweden
Iceland
France
Norway
Germany
Luxembourg
Netherlands
Austria
Finland
Italy
Japan
Australia
Belgium
Denmarti
U.K.
New Zealand
Ireland
Spain
Portugal
Greece
1*83
1^53
1274 I
1,234
1^32
1,193
^
286
407
535
Source: Schiober.G J.. Poultor J-P., Haalth Affairs, Spring 1991. -International heaith spendng: Issues and trends'.
Rg. 5 -Total Health Expenditures as a Percent of Gross
Domestic Product (GDP): Selected OECD Countries, 1970 -1989
12
-
10 -
It is in this context that COGME has beet
examining physician workforce supply and distribution and its impact on ensuring access to care foi
all Americans. Over the past two years, the Council has focused on the following seven major questions:
8 -
6 _
United
Kingdom
41970 72
tion system producing the right mix and supply of
physicians to meet our Nation's health care need'
in the 21st century? Clearly, efforts to solve the trie
of inadequate access to care, skyrocketing costs
and poor relative health status would be significandy hindered if America is also facing a crisis ii
physician workforce supply.
74
78
78
80
82
84
88 . 88
Souioe: Pm-1988 data: OECO. Health Data Fie, 1969. Irom Health Care Fnmdng AOnnstiation. 196849 data: Schaber. GJ.
and Poullier. J-P. 'Intamational health spending' Issues and trends.' Heath AAus, Spring 1991.
The Crisis in Physician
Workforce Supply
Physician and health professional workforce
considerations are fundamental to any discussion of
health care reform strategies. The ability to provide
essential health care services to all Americans depends upon the proper supply, racial/ethnic composiuon, specialty mix, and geographic distribution of
physicians and other health professionals. If a system of insurance was provided tomorrow for all
Americans to ensure access to essential health care
at a reasonable societal cost, would the right mix of
physicians be available to provide quality and costeffective care? Furthermore, is our medical educa-
1. Do we have an adequate mix of generalists and specialists to provide the most efficient ani!
the most cost-effective system of quality care for al!
Americans?
2. What implications do problems of acces.'
have for recommendations on physician workforce,
supply, and distribution?
3. What is the status of minority representation in medicine and what effect does it have oc
minority health as well as the health of the public ii
general?
4. What are the supply needs of specific medical specialties?
5. Do we currently have adequate number
of total physicians? Will the projected supply o!
physicians be adequate?
6. Can our medical education system be mort
responsive to the health care needs of the Nation?
�THIRD REPORT OF COGME
7. What are the factors that have hindered
effons to attain the appropriate composidon, specialty mix, and geographic distribution of physicians to ensure access to care for all Americans?
References
1. Schroeder, S.A., Zones,J.S., Showstack,J.A.
Academic medicine as a public trust. Joumai of the
American MedicalAssociaiion 262(6):803-12,1989.
Over a two-year period since its last report, the
Council received a broad range of input. This
included solicited papers covering supply and demand for physicians, barriers to access to physician
services, and updated need-based requirements for
selected specialties. The Council limited its review
of workforce assessments to the following specialties: general/family practice, general internal medicine, general pediatrics, general surgery, obstetrics/
gynecology, adult and child psychiatry, preventive
medicine, and geriatrics.
S35
iply of
needs
he trio
costs.
m
; been
distriare for
Coun• quesmeralntand
foraL
access
dorct.
•sentaive OE
blicin
medi-
mbe: ^ ^
i b
Pi
:more
tion?
2. McGinnis, J.M., Hamburg, M.A. Opportunities for health promotion and disease prevention in
the clinical setting. Western Joumai of Medicine
149:468-74, 1988. Cited in Schroeder et al., ibid.
The Council received significant testimony at
plenary sessions and before its three subcommittees
on Physician Manpower, Medical Education Programs and Financing, and Minority Representation
in Medicine. Representatives from major organizations and policy-making bodies, including the major allopathic and osteopathic hospital and medical
education organizations and major specialty organizations, have testified on aspects leading to this
third report. Major foundations have provided testimony, including the Josiah Macy, Jr. Foundation,
the Robert Wood Johnson Foundation, the Pew
Charitable Trusts, and the Kellogg Foundation. Representatives of State and local interests, such as the
New York State Council on Graduate Medical Education and the National Conference of State Legislatures, also testified. In addition, COGME has
reviewed the latest recommendations from medical
educators and policymakers on medical education
reform policy.
5. Schwartz, E., Kofie, V.Y.,Rivo,M.,Tuckson,
R.V. Black/white comparisons of deaths preventable by medica] intervention: United States and the
District of Columbia 1980-1986. International Journal of Epidemiology 19:591-98, 1990.
This third report to Congress and the Secretary
provides the Council's principles and subsequent
findings, goals, and recommendations to address
these major physician workforce issues of today.
Chapter II contains the Council's first six major
findings and goals. Chapter I I I contains the
Council's seventh major finding and goal, which
describes the major barriers to policy change that
must be addressed to attain the goals and new directions. Chapter IV describes the Council's recommendations for the Nation, as well as specific recommendations for our Nation's medical educators.
The appendix contains projections of the total physician supply and specialty mix if COGME's recommendations were adopted.
3. Foley, J. Sources of Health Insurance and
Characteristics of the Uninsured: Analysis of the
March 1991 Current Population Survey. Washington, DC: Employee Benefit Research Institute, 1992.
4. Education Benefit Research Institute. Issue
Brief, July 1990.
6. Billings, J. Presentation to the Council on
Graduate Medical Education, September 5, 1991.
7. Davis, K., Rowland, D. Uninsured and
underserved: Inequities in health care in the U.S.
Milbank Memorial Fund Quarterly/Health and Sc
ciety 6\(2): 1983.
8. Department of Health and Human Services.
Health, United States and Prevention Profile 1991.
USDHHS Pub. PHS-92-1232, 1992.
9. Schieber, G.S., Poullier, J.P., Greenwald,
G.S. Health care systems in twenty-four countries.
Health Affairs 10(3):22-38, 1991.
10. Renn, S.C. The structure and financing of
the health care delivery system of the 1980s. In:
Schramm, CJ. Health Care and Its Cost: Can the
United States Afford Adequate Health Care? New
York: W.W. Norton and Company, 1987.
11. Schieber, et al., op. cit.
12. Aitman, S.A. Presentation at the National
Primary Care Conference, Washington, DC, March
30, 1992.
�THIRD REPORT OF COGME
Chapter II - Findings of COGME
Finding No. 1:
The Nation has too few generalists and too
many specialists.
• The growing shortage of practicing generalists (i.e., family physicians, general internists,
and general pediatricians) will be greatly aggravated by the growing percentage of medical
school graduates who plan to subspecialize. The
expansion of managed care and provision of universal access to care will only further increase
the demand for generalist physicians.
• Increasing subspecialization in U.S. health
care escalates health care costs, results in fragmentation of services, and increases the discrepancy between numbers of rural and urban physicians.
• A rational health care system must be based
upon an infrastructure consisting of a majority
of generalist physicians trained to provide quality primary care and an appropriate mix of other
specialists to meet health care needs. Today,
other specialists and subspecialists provide a significant amount of primary care. However, physicians who are trained, practice, and receive
continuing education in the generalist disciplines
provide more comprehensive and cost-effective
care than nonprimary care specialists and
subspecialists.
Many Americans lack access to basic primary
health care, which includes a comprehensive range
of public health, preventive, diagnostic, and rehabilitative sen ices. The goal of these services is to
prevent premature death and disability, preserve
functional capacity, and enhance overall quality of
life.
Building a health care system that ensures the
availability of these services is a fundamental goal.
Ensuring the right mix of health professionals to
deliver these services is another prerequisite. A
wide variety of health professionals can and should
be delivering primary health care services using
both individual and public health approaches. For
example, important clinical preventive services, such
as immunizations, are frequently delivered in the
public health sector by preventive medicine/public
health physicians and public health nurses.
The emphasis on high-cost, disease-oriented,
hospital-based, subspecialty medical care at the expense of low-cost, person-oriented, communitybased primary care is a growing cause for concern.
The limited number of primary care providers in
the United States intensifies the barriers to access
for all Americans.
A critically important element of any health
care system is primary medical care. Primary medical care is characterized by the following elements:
• First-contact care for persons with undifferentiated health concerns.
•Person-centered, comprehensive care that is
not organ or problem specific.
• An orientation toward the longitudinal care
of the patient.
• Responsibility for coordination of other health
services as they relate to the patient's care.
Physicians who provide primary medical care
are trained as generalists. They are trained in,
practice, and receive condnuing education in the
following competencies:
• Health promotion and disease prevention •
Assessment/evaluation of common symptoms and
physical signs. • Management of common acute
and chronic medical conditions. • Identification and
appropriate referral for other needed health care
services.
Once the elements and competencies of primary care are clearly defined, the physician specialties that compose the "primary care" disciplines
become evident. Physicians who provide these
comprehensive primary care services are trained in
and practice as "generalists." Generalist physicians
who attain these competencies through specific training and certification, practice, and continuing education include family physicians, general intemists,
and general pediatricians. In addition, other
nonphysician providers meet this definition, including primary care physician assistants, nurse practitioners, and certified nurse midwives. The important role of these nonphysician primary care providers is beyond the scope of this report. It will be
addressed in a future repon.
Once defined as such, these generalist physicians and nonphysician primary care providers are
distinguishable from a diverse spectrum of other
�THIRD REPORT OF COGME
essential health professions that are needed to deliver health care, such as cardiologists, obstetrician/
gynecologists, psychiauists and other physician specialists, public health nurses, social workers, dentists, and phannacists. These other professionals
receive training in and provide some important aspects of what we have defined as primary medical
care, such as the cardiologist managing a patient's
angina, the surgeon providing followup for a woman
with a breast lump, the denust performing an oral
exam, or the public health nurse providing immunizadons. However, these professionals are not trained
in, practice, and receive condnuing medical education in the broad competencies of primary medical
care.
In addition to their regular three-year residency,
generalist physicians may acquire additional training to deliver primary medical care to specific populadons. For example, although all family physicians and general intemists acquire substantial residency training experience in caring for the elderly,
some obtain additional training in geriatrics. Although all family physicians and general pediatricians are trained during residency to care for adolescents, some obtain additional training in adolescent medicine. Furthermore, some family physicians, general intemists, and general pediatricians
acquire additional training in prevendve medicine/
public health.
These areas of additional primary care training
differ significandy from subspecialty training (e.g.,
cardiology, nephrology, and gastroenterology).
They are person-, family-, and community-centered
rather than organ-specific. They focus on building
additional competencies and skills in the elements
of primary medical care.
R g . 6 - A Steady Decrease In Primary Care MDs*
Compared to Other Specialties: Selected Years 1931-88
There has been a general consensus f
years in the policy-making community l
Nation, we have been training too many subspeciali
physicians and not enough generalist physicians:
provide primary medical care. Over the last 6
years, the change in the national specialty distrik
don of physicians has been dramatic. In 193:
more than four out of five private practice phy*
cians were in general practice. By 1965, the pn
portion had dropped to less than one-half. By 1 8
9>
the proportion of physicians in the generalist s e
p
cialties had decreased to approximately one out c
three (figure 6).
1
In 1990, 33.5 percent of the 547,310 activ
allopathic physicians were generalists. They cot
sisted of 76,295, or 13.9 percent general internist
70,480 or 12.9 percent family physicians, and 36,51'
or 6.7 percent general pediatricians. Of the 22,65:
active osteopathic physicians reporting a specialr
in 1990, 55.4 percent were in general practice.
This declining generalist physician infrastruc
ture significantly hinders access to basic primar
medical care. Physicians in these generalist spe
cialties provide over half of all ambulatory patien
contacts. The 1985 National Ambulatory Medici
Care Survey found that approximately 30.
-n
of ambulatory visits were to family physic.
;i
percent to intemists (excluding cardiologists), anc
11.4 percent to pediatricians.
The roots of these trends can be traced to initiatives previously described that resulted in the increased production of physicians. Following Work
War II, the Nation invested unprecedented amount'
of funds in biomedicalresearch.The Federal Government became the dominant source with fund'
principally channeled to the Nation's medicai
schools through NIH. While this investment ha.'
produced many of the world's greatest advances ir
research and medical care, it has also proved to be a
key factor in the rise of specialization.
2
Primary Care
Non-Primary Care
80-
3£
37
_ 60
a
40-
Concern over the generalist erosion in the physician supply has been expressed for at least twe
decades. The Report of the Citizens Commissiot
on Graduate Medical Education (the Millis Report'
in 1966 cited the increasing specialization in the
physician supply as the chief factor in the asynchron)
between the availability of medical services and the
health care needs of society. Indeed, much of the
health workforce Federal legislation since the 1960s
has been created to correct the following •
'ed
impediments: (1) an insufficient numbei
.eralist physicians; (2) a disproportionately large number of specialists relative to generalists; and (3) ar
uneven geographic distribution of physicians. 3
200 -
I
1931 49 60 61 62 63 64 65 66 67 68 69 70 8 88
1
' F»m*y physicians, general Imemists and general pertielririana
I M e : TTie AMA recJasaihed MDs in 1968 causing a 3 3 % change in pnmary and non-prima/y care.
Source: Pre-i 965 data from Health Manpower Sourcebook: Section 14. Medcal Speaaliss. Division ol Public Health Methods,
U.S. Public Health Service. DHEW. 1962. 196548 data from Pfysoan Chaiactenstxs ana Diahbution. annual editions. AMA.
!
4 5
�THIRD REPORT OF COGME
Yet, the goal of shifting specialty distribution
toward primary care has not been achieved. In its
most recent report, the Physician Payment Review
Commission (PPRC) notes that some past policies
may have been ineffective because they were
underfunded, had insufficient support, or the problems they were intended to address were no longer
considered priorities. These policies were also unsuccessful because they were undermined by other
policies that created addiuonal and more substantial financial incentives for growth in subspecialty
residency positions. Such policies included biomedical research funding, financing GME through
the hospital, and payment policies that overpaid
surgical and technical procedures relative to evaluation and management services.
rent declining interest in primary care is not transitory.
Even if the supply of new physicians is significantly reduced, the total supply of physicians will
continue to increase well into the next century.
Currently, over twice as many physicians enter practice annually as retire. Consequently, the generalist/
specialist mix of physicians becomes important,
nol only in addressing specific health needs of the
population but also to contain health care costs.
The following observations are particularly relevant:
The result of this movement among medical
school graduates toward increasing subspecialization
suggests that our health care system in the next
century will be even more subspecialty based with
only one-fourth of physicians viewing themselves
as primary physicians. Current trends toward
subspecialization are accompanied by the following health care concerns:
6
• In its first report in 1988, COGME recommended increased numbers of physicians in family
practice and general internal medicine to assist in
meeting problems of access to primary care services.
7
> initia
the in
Woric
nounu
1 Govfund'
edical
nt ha.'
ices ir
obea
• The demand for practicing generalists would
markedly increase if a program of universal health
insurance is to be implemented. (One estimate is
for a 13- to 15-percent increase in primary physician patient contacts. )
8
• Interest by medical school graduates is rapidly increasing in procedurally oriented
subspecialties and in subspecialties that are perceived to offer more controllable lifestyles. - (The
surgical specialties in which the number of residency positions has not increased are exceptions to
this trend.)
9
h
- P yt two
issior
:poni
n the
iron)
id the
if ihe!
960s'
jived
;nerlur
10
• Interest in the primary care specialties is declining dramatically among U.S. medical students.
11
The Association of American Medical Colleges' (AAMCs) Graduation Questionnaire, which
is an accurate aggregate predictor of specialty
choice, indicates that interest in family practice,
general internal medicine, and genera] pediauics
has fallen from 36 percent of graduating seniors in
1982 to 22.7 percent in 1988 and 14.6 percent in
1992. Long-term trends in specialization and
subspecialization in medicine suggest that the cur12
13
Current Health Resources and Services Administration (HRSA) projections of physician
workforce are based upon the 1986 American Medical Association (AMA) Physician Master File and
the assumption that physicians in residency training
will follow historical trends of subspecialization.
These projections indicate that 32 percent of physicians will describe themselves as primary care physicians in 2010. However, when this model of
physician supply is modified to utilize a scenario
that 20 percent of graduates will become generalists, then the percentage of primary physicians is
predicted to drop to 28 percent in 2010 and to 26
percent in 2020.
• Primary care services increasingly will be
provided by subspecialists who will have had little
or no education for primary care.
• Primary care services provided by
subspecialists can be expected to cost more.
Subspecialists providing primary care are likely to
seek consultation more frequendy because of the
narrower focus of their education. Services provided will increase and will result in fragmentation
and replication of care as patients shop from
subspecialist to subspecialist. 1415
1617
• An oversupply of subspecialists would be
more costly than would an oversupply of generalists. Subspecialists would be expected to use the
technology and procedures of their subspecialty
and to use hospital resources more than would generalists. A recent study showed that, even after
controlling for patient mix and illness acuity,
subspecialists such as endocrinologists and cardiologists perform more tests, prescribe more medications, and hospitalize more frequently than general intemists, and general intemists tend to use
similar but slighdy more health care resources than
family physicians. An editorial on this study
argued that the differences in utilization almost
certainly understated the tme differences in costs
between specialists and generalists because the study
measured resource use, not charges, and because
specialists charge and are paid more for identical
services provided by generalists.
18
19
�THIRD REPORT OF COGME
coordinated care by generalist physicians ar*-'
costly. In addressing possible future change
health care system, utilization review, develo,.
of coordinated care programs, funding for pre\f
tive services, increased consumer cost sharing
health insurance, and the implementation of unive
sal health insurance all will impact more positivt
upon the need for more generalist physician k
vices than for specialty physician sen'ices.
Fig. 7 - Generalists as a Percentage of Physicians:
Selected Nations, Early 1980s
80-
S
73
54
60-
GP/FP
53
47
3
40-
!
27
38
-
34
The 1978 Institute of Medicine (IOM) study
primary care workforce supported the Federal ir
tiative at that time that 50 percent of medical scho
graduates should enter residencies in primary cr
specialties. The study also indicated that it W L
O
be desirable for 60 to 70 percent of graduates
enter primary care specialties, in view of a shorn,
of primary physicians.
28
0United Germany Belgium Canada Netherlands U.S.
Kingdom
Source: Schroeder. S.A.. and Physician Charactenstia and Disthbirtion, AMA. 1983. JAMA. 252:37344.
•Western European responses to physician oversuDpty".
• Increasing specialization will result in a growing discrepancy between the rural and urban physician workforce because subspecialists practice in
urban areas. Current AMA projections anticipate a
24-percent increase in metropolitan physicians between 1987 and 2000 and only a 17-percent increase in rural physicians. These differences are
understated because the projecuons do not take into
account the declining interest in family practice—
the specialty most likely to serve rural populations.
20
• Subspecialists providing more generalist services will devote less time to their preferred subspecialty area. This plus the oversupply of
subspecialists reduces an individual subspecialist's
opportunity to care for the more complex and rare
problems in the field. This may have negative
implications for competence in the subspecialty area
as well as for physician satisfaction.
21
Experimental data do not exist to define the
ideal proportion of generalists and specialists needed
to provide optimal access to primary care services
and optimal availability of secondary and tertiary
services in the most cost-effective manner. However, in most Western nations, the percentage of
generalist physicians far exceeds that of the United
States. Fifty percent of Canadian physicians and 70
percent of British physicians are general practitioners or family physicians (figure 7). - -
However, the IOM did not anticipate the exte '
to which subspecialization would occur in intern •
medicine and pediatrics by the 1990s. Recent sc •
vey data indicate that 40 percent of those plannk
careers in pediatrics expect to subspecialize and
least 60 percent of those planning on careen:
internal medicine expect to subspecialize.
29
By contrast, family medicine has t
subspecialties. More than 95 percent of ti
enter family medicine residencies practiceralists. In addition, family physicians are trains
to provide primary medical care to all ages and bot
sexes, while pediatricians are trained to care ft
children and adolescents, and internists are traine
to care for adults and the elderly.
Family practice differs in another key dimet
sion: it is the only specialty to be evenly distribuie
across all county types and sizes. While the pe
capita physician-to-population ratio for family pb
sicians is actually higher in nonmetropolitan area.these same areas have, per capita, in comparisc
with metropolitan counties, fewer than one-third a
many general intemists, approximately one-fouit
as many general pediatricians, and slightly mot
than one-fifth as many obstetricians/gynecologists.
22
23
24
25
Furthermore, the most cost-efficient delivery
systems within the United States are closed-panel
HMOs that employ approximately 50 percent primary care physicians. The rapid proliferation of
HMOs in which primary care physicians rather than
subspecialists serve as case managers suggests that
26
Finding No. 2:
Problems of access to medical care persist
in rural and inner-city areas despite large
increases in the number of physicians
nationally.
• Access to primary care services « espe
daily difficult in rural and inner-r
ea
Many factors contribute to the probk
i at
cess, including economic and social circumstano
of rural and inner-city areas as well as the shor
�11
THIRD REPORT OF COGME
age of minority and generalist physicians. Minority physicians and physicians in the three
primary care specialties (family practice, general internal medicine, and general pediatrics)
are more likely to serve inner-city populations.
• Family physicians and general surgeons
are more likely than other specialties to serve
rural populations. The decline in numbers of
general surgeons entering rural practice is little
recognized and has significant implications for
access to trauma, obstetrical and orthopedic services in rural settings and to the fiscal viability
of rural hospitals.
elopmei
•r prevei
haring i
of unive
jositivel
ician se
27
1
study c
deral ir
al scha
lary ca;
it won!
Juates i
shortaj
needed in these settings. This must be accompanied by sufficient incentives to enter and remain
in inner-city and rural practice and by the development of adequate health care systems in which
they can practice.
• Access to one important component of primary medical care, obstetrical services, has been
in the national spotlight Problems are greatest
in rural and inner-city areas. Causes include
economic and sociocultural factors and the availability of obstetricians, family physicians, and
nurse midwives. While the total number of obstetricians continues to increase, the proportion
providing obstetrical services decreases dramatically with the number of years in practice. Less
than 10 percent of obstetricians practice in rural
settings. Consequently, family physicians historically provide the majority of rural obstetrical care. In recent years, however, the proportion of family physicians providing obstetrical
services has also declined markedly. While rising malpractice claims clearly have contributed
to the decreasing provision of obstetrical care,
other factors, such as unpredictable hours, also
seem to have contributed to these decisions.
• Consequently, more minority and generalist physicians must be educated and educational
programs should specifically address skills
leexter t
Fig. 8 - Number of Health Professions Shortage Areas (HPSA) and
Number of Physicians Needed to Remove HPSA Designation
intenii |
;ent su:
plannin
'.e and;
ireers i
5,835
Number of Physicians
Needed to Remove Designation
4,314
s
o:
4,496
4 I
2,189
2
_
1,921
1,949
3
O
a
^
g
as eer
traine
ind bot
care fc
traine
dimet
tribute,
the p
e
ily ph\
n area
parisoihird a
-fourtfl
y mori'
•gists.-
in
a:
3
3
Q.
Z
a.
0
ar
_
Dec 1986
Mar 1992
Number of Hearth Professions Shortage Areas
>.-JX? HRSA. Bj'eau ol Pnmary Hearth Care
Fig. 9 - Non-Federal Primary Care Physicians (MD & DO),
by County Size, 1988
Population
5,000,000 +
1,000,000 - 4,999,999
500,000 - 999,999
50,000-499,999
< 50,000
50,000 +
25.000 - 49,999
10,000 - 24,999
5,000 - 9,999
2,500 - 4,999
<Z500
rsist
arge
of a ^ ^
tance
31
32
Dec 1980
1
Short-
!
m 1 _
The issue of an unbalanced geographic distribution of physician resources has been the topic of
research and an issue for policymakers for quite
some time. A paper prepared for the Council
indicated that, while perceptions of shortages of
physicians in rural America date as far back as the
late 18th century, and the relative shortage of
physicians outside of cities was accepted as a reflection of the comparative attractiveness of practice in urban areas, the degree of differences were
not considered crucial until the 1960s. At that time,
studies showed that urban/rural and inner city/suburban differences were increasing and that the time
may come when the American rural generalist would
disappear.
Metropolitan I
Non-Uetropolitan
I
I
1
20
40
«0
Physicians Par 100,000 Population
I
ao
S o r e Bcetu.T.C earners toAccass to Services PrmiOeel by Physidtns in Geneml^amily Madicine. General Inumal
**«>one Genera/ Pediatrics. General Surgery, Obstetrts/Gynecology. and General and ChUd Psyctoarry. 1991.
The response to this problem during the 1960s
was to increase the size of medical school classes,
to provide new Federal funding for the production
of primary care physicians, and to open new medical schools that would emphasize primary care training. The result was a sharp increase in the number
of physicians. Several studies showed a pattern of
"diffusion" of physicians into rural and geographically isolated areas. - More recent studies have
addressed the limitations of these reports and have
concluded that this diffusion has not been sufficient
to resolve the shortage problem in rural areas. Indeed, as seen below, the number of Health Professions Shortage Areas (HPSAs) in the United
States acmally increased despite a doubling of the
33; M
35
36 37
�THIRD REPORT OF COGME
1
Fig. 10 - Ratio of Physicians Per 100,000 Population by Non-MetropolHan
and Metropolitan Location and Primary Care Specialty
31.9
30-
29.2
Non-MetropoUtan
MsiropoinBn
253
1
20-
1&5
s
14^
4
0
i
iai
1"
I
0 -
Gen Ped
OtVGyn
Souroe: HRSA. R m l Haalth Prvtessions Facts. Swp*- and DisBibution ol Health PmtassKXtals i t flu* Anonca. HRSA 1992
Fig. 11 - Percent of Physicians in Each Primary Care Specialty and Percent
of U.S. Population by Non-Metropolitan and Metropolitan Location, 1989
91J
80
Non-Metropolitan
Metropolitan
Family/general practitioners are the only :
cialists to be evenly distributed across all cou:
types and sizes. Nonmetropolitan counties lu
fewer than one-third as many general intemists L
general pediatricians and slightly more than o
r
third as many obstetricians/gynecologists per cap
compared with metropolitan counties (figures
and 11 ).
;
5^
4.6
GIU
FP/GP
922
74.9
U.S. Population
60 |
Physician geographic diffusion has been
ited. A study of physician availability in 6
ties with fewer than 10,000 population fc
while the average level of physician availab
increased by 34 percent in the United Statestween 1975 and 1985, it increased only 14 peic;
in these small rural counties. Primary care ph,
cian-to-population ratios increased by 27 percen:
metropolitan counties, 42 percent in nonmetropol:
counties, and only 9.4 percent in counties s
fewer than lO.OOO.
40-
41
COGME, in examining these issues, reach
the following conclusions in its 1988 report: >
there is a geographic maldistribution of physicia:
with too few in many rural and inner-city areas; i
the problem is not as severe as it has been in c
recent past and may well be ameliorated, at least
part, as the overall supply of physicians incase
and (3) geographic maldistribution rema
ever, a serious problem, requiring mort
J
based solutions than those focusing exclusively >
medical education. Since then, as previously nou
the number of primary care physician shortage a
eas and the number of medically underserved pt
sons have been increasing despite the continue
growth in the physician supply. More focused at
significant changes in the medical education, i
nancing, and health care reimbursement systen
are clearly now needed to eliminate these shortas
areas.
42
25.1
U.S. Population
20 0 GP/FP
GIM
Note: PopUationistor1990
Gen Ped
GP/FP
GIM
Gen Ped
Source: HRSA Aura/ Health Professions Facs. St&jfy and Distribution ot Health Protessnnais in Rural America. HR&\. 1992
physician supply (figure 8). A background paper
prepared for the Council noted that physician distribution is skewed significandy away from small
towns and rural areas and that many Americans are
too far from a physician who can see them on a
timely basis.
38
Figure 9 reflects the substantial geographic
variation of available primary care physicians to
care for the Nation, with the large metropolitan
areas in 1988 having three times the number per
population compared with the smallest
nonmetropolitan area counties. In that year, 176
counties with a combined population of 713,700
had no primary care physician. All of these counties were nonmetropolitan with 25,000 or fewer
residents; 166 counties had 10,000 or fewer residents.
39
Federal and State programs have been of crit
cal importance in addressing the relatn
undersupply of physicians in rural and inner-cit
areas; they will continue to be needed for at lea:
the remainder of the decade. Maintaining and ii
creasing resources for these efforts will require ot
going political support at Federal, State, and loc
levels. These have taken the form of educatioru
intervention at medical undergraduate and gradual
levels, establishing public delivery systems in run
and inner-city areas, and providingfinancialincec
lives for practice in such areas. Examples of sue
cessful federally supported initiatives to ' --as
primary care physician supply and servict
.'d;
areas include family practice residencies, tht. .iriSC
Indian Health Service (IHS), the Area Health Edu
cation Centers (AHECs), community and migrac
�13
THIRD REPORT OF COGME
health centers, and some financing strategies. Evaluation has not indicated which strategies are the
most efficient, but it is believed that multiple integrated strategies are the most effective.
43
Problems of access to obstetrical services have
proved to be of increasing concern. The availability of these services depends on access to obstetricians, family physicians, and nurse midwives. Less
than 10 percent of all obstetrician/gynecologists
practice in rural settings, and family physicians
historically provided the majority of rural obstetrical care. ' In recent years, however, the number
and proportion of family physicians providing obstetrical services have markedly declined. In addition, with increasing years of practice, many obstetricians/gynecologists decide to stop providing obstetrical care.
44 45
In the past several years, numerous State studies have documented a decline in the number of
physicians providing obstetrical services in rural
areas. Several of these studies have linked this
decline to rising medical malpractice costs. Constructing strategies in response to provider concerns over obstetrical liability is one essential component in shaping policies to reverse the shortage of
obstetric services.
46
47
Finding No. 3:
portionately high rates of poverty, poor health
status, poor schools, and a continued lack of
access to educational and career opportunities.
They must include both traditional short-term
efforts and long-term strategies targeting
younger students early in the education pipeline.
African Americans constitute 12.1 percent of
the population, but only three percent of all physicians. Likewise, Hispanic Americans constitute
nine percent of the populadon, but only four percent of physicians. Native Americans are 0.8 percent of the population but only 0.1 percent of all
physicians. Underrepresented minorities will continue to grow as a proportion of the total population. By the year 2000, African Americans are
projected toriseto about 13 percent and Hispanics
to about 11 percent of the total population, or over
24 percent of the total population for these two
racial/ethnic groups. Indeed, people of color will
make up 29 percent of the new entrants into the
labor force for the period between 1987 and 2000.
48
49
50
The predominant minority populations of the
United States can be categorized as African Americans, Hispanic Americans, Asian and Pacific Islander Americans, and American Indian and Alaska
Natives (the inclusive term for these last two groups
is Native American). Within each racial or ethnic
category, significant subgroup differences can be
found. When we speak of underrepresented minorities we are referring to those individuals with
lower representation in health and allied health professions schools than in the general population.
Currently, African Americans, Hispanic Americans,
and Native Americans are underrepresented; Asian
Americans overall are not, although certain Asian
American subgroups are underrepresented.
51
The racial/ethnic composition of the
Nation's physicians does not reflect the
general population and contributes to
access problems for underrepresented
minorities.
of oil
elath
ler-cit
at leaand ii:
lire or
d loa
ation:
aduav.
nrun
incer
3f f
icrti
nefl
>JHSC"
i Edu ;
ugrar.
• Although African Americans, Hispanic
Americans, and Native Americans compose 22
percent of the total population and will constitute almost one-fourth of all Americans by the
year 2000, they represent only 10 percent of
entering medical students, 7 percent of practicing physicians, and 3 percent of medical faculty.
• Increasing the percentage of
underrepresented minorities in the medical profession is vital as a means of improving access to
care and health status of these vulnerable and
underserved populations. Minority physidans
tend to practice more in minority/underserved
areas, reduce language and cultural barriers to
care, and provide much needed community leadership.
• Strategies to increase minority enrollment
must emphasize increasing and strengthening
the applicant pool, the acceptance rate from
within this pool, and the student retention rate.
These strategies must take into account dispro-
52
The chances for an underrepresented student to
be admitted to medical school today have actually
become more remote as their proportion of the total
U.S. population increases. It is not possible to
understand this assertion nor the underrepresentation
of minority physicians in medicine without a historical framework.
The acceptance of
underrepresented minorities in predominately
"white" (i.e., majority) medical institutions in this
country has been very slow. Majority medical
schools have historically discriminated against these
individuals, and in the case of African Americans—
for whom the most documentation exists—majority medical schools have had a history of segregation, which resulted in segregated and overcrowded
teaching institutions for African Americans.
53
5 4
History indicates that the colonizers came to
the New World believing that people of color were
inferior, and used that ideology to justify the en-
�THIRD REPORT OF COGME
slavement of African Americans, the decimation of
Indians and Mexicans, and the importation of Asians
to perform work that was considered unfit for whites.
By the 1900s, racist attitudes and practices were
institutionalized in laws, religion, and in the very
culture of America. The minority groups were
made to feel inferior and alienated by the majority
culture. A psychiatrist who has spent a lifetime
studying this phenomenon states that this social
process of inferiorization is achieved through the
imposition, from birth to death, of a stressful, negative and nonsupportive social/environmental experience upon the people who are to be inferiorized.
This negative and stressful social experience, which
is structured to affect every aspect of life activity,
produces a negative self-concept, a loss of selfrespect, and the development of self-destrucuve
and group-destructive behavioral patterns.
preceptorships or schools. Not all of t
were trained elected to go to Liberia; s^....;
mained in the United States to practice.
The conventional educational process (as an
instrument for acculturation and entrance into careers in the United States) has historically been
severely restricted for minorities. - One must not
underestimate the impact of this aspect of institudonal racism on the psyches and the behavior of
minority peoples in the United States. Although
slavery became illegal more than 100 years ago, the
300-plus years of experiencing its brutality and
unnaturalness has produced a severe and continuing psychological and social shock to African Americans. Psychologists and sociologists have failed to
attend to the persistence of problems in the mental
and social lives of African Americans, which clearly
have their roots in slavery.
According to Petersdorf. et al., for many yez
America's medical schools mirrored the discrin:
nation of society. Thus, they were primarily tt
preserve of white males. The chaotic conditioi
following the Civil War and the assassination
President Lincoln gave rise to a new dimension
American health care—separate and
"<>ati
medical schools. In 1868, the first Afri
ie
can medical school, Howard Univei-. w
founded as a coeducational, multiracial instituti
in Washington, D.C. Interestingly, the earliest me
cal classes had more students of European desa
than of an African descent. - Meharry Medi
College in Nashville, the second African Americ
medica] school, was organized in 1866 and bej
to function in 1876. - -
55
56
57
58
59
67
Regarding other currently underrepresent
minorities, one of the earliest Hispanic physicia:
to graduate from an American medical school»
Cuban-bom Carlos Juan Finlay. He was awari
the M.D. in 1865 by Jefferson Medical College
Philadelphia. - It appears that the first Nati
American to receive an M.D. from an Americ.
medical school was an Omaha woman who i
ceived it in 1889 from the Women's Medical G
lege in Philadelphia. A Native American male
Santee Sioux descent received his M.D. a year lai
(1890) from Boston University.
68 69
70
Predominately Minority Medical Schools
Are Founded
71
72 73
7 4 75
Minorities Enter U.S. Medical Schools
Although the first medical school in the United
States was established in 1765 in what is now the
University of Pennsylvania, African Americans
and other minorities were not admitted to majority
medical schools for more than three-fourths of a
century. However, African Americans who had
been trained in Europe practiced in the colonies in
the 17th, 18th, and 19th centuries. The idea
or value of training African Americans for medicine was generally frowned upon in the early 19th
century. It was not until 1847 that the first African
American received a medical degree from an American institution. This individual graduated from
Rush Medical College in Chicago.
However,
up to the middle of the 19th century, in response to
efforts of the American Colonization Society (Back
to Africa), African Americans who wished to practice in Liberia were accepted for training in
6061
62 63 W
65 6 6
It was in the highly segregated environmeni
the Post-Reconstruction era that African Amerii
medical schools and hospitals appeared. In
late 1800s, there were 14 predominately Afrii
American medical schools. Until 1950, majo
medical schools had graduated fewer than 15 f
cent of African American physicians. The majo
ofthe remaining African American physicians w
graduates of Howard and Meharry medi
schools. Currendy, the other African Ameri
medical schools in the United States are Drew M'
cal College in Los Angeles, founded in 1966,
Morehouse College of Medicine in Adanta, foun
in 1978. There are three Hispanic med
schools: all are located in Puerto Rico. These scb
are the University of Puerto Rico Sch'
"M
cine in San Juan (1949); the Universidc
era
Caribe in Bayamon (1976); and Ponce 5choc
Medicine (1980). There are no Native Amer
medical schools.
76
77
78
79 80
81
�15
THIRD REPORT OF COGME
Civil Rights and Minority Medical
Students
It was not until after the landmark civil rights
court decisions and the legislanon of the 1950s and
1960s that all majority insutudons were opened to
minority candidates. As many as 200 historically
African American hospitals have been identified
dating to the 1800s. Prior to 1965, the African
American hospitals were crucial. If they had not
existed, many African Americans would have had
no health care, and the African American medical
profession would have been destroyed, because only
a very small number would have been permitted
internships and residencies in non-African American hospitals.
82
career opportunities for women, minorities, and the
economically disadvantaged. As a result, affirmative-action programs were implemented by many
medica] institutions.
85
In 1970, an AAMC task force called for an
increase infirst-yearunderrepresented minority enrollment to 1,800 by the year 1976. This number
would have corresponded with what was at that
time the total percentage of the underrepresented
minority groups in the United States (12 percent). *Underrepresented minority medical school student
enrollment rose to nearly 1,500 (10 percent of the
entering class) by 1974. However, the 12 percent
enrollment goal has never been met.
8
87
83
During the 1950s and 1960s, when 10 percent
of the total U.S. population was African American,
only 2.2 percent of all physicians were African
American. The numbers would have been far more
dismal if three-fourths of all African American physicians had not been produced by Howard and
Meharry medical schools. Mexican Americans,
mainland Puerto Ricans, and American Indians,
which constituted about three percent of the total
population in the mid-1960s, accounted for less
than 0.2 percent of the total medical school enrollment.
84
•
tmeai
Fig. 12 - Underrepresented Minorities (URMs) as a Percent of the
U.S. Population and Medical School Matriculants: 1970 - 1 9 9 0
The increase in minority students during the
1970s resulted from the following:
• An expansion of the minority applicant pool
as well as a residue of qualified applicants from
earlier years.
• An increase in the availability of scholarships
and loans.
• Improved minority recruitment practices of
medical schools.
• The establishment of special programs to
assist minority students to strengthen their candidacy for health professions in general.
• A 50-percent increase in the number of firstyear medical school positions made possible in pan
by the opening of 25 new medical schools between
1964 and 1974.
88
89
20
• 18.5%
(75 - 90)
15
i
lencar
Medi•6, and
'unded'
icdical;
choob'
Medi-'
traJ -'
URM Population
Minority Medical Students in the 1980s
and 1990s
As affirmative action programs established a
trend toward greater minority student panicipation
in medical education, which approached the levels
set by the AAMC, legal challenges to affirmative
action surfaced. In a landmark case in June 1978,
the Supreme Court ruled against the University of
California-Davis in the Bakke decision. The Supreme Court found lhat it was illegal to set "quotas"
(setting aside of a set number each year) for minority enrollment, but appropriate to set an institutional goal for attaining greater diversity. The
Bakke decision had a "chilling effect" on the entrance of underrepresented minority students in the
health professions schools. In addition to the
Bakke decision, actions by the Department of Justice in the civil rights area hindered the progress
that had been made. - 90
URM Matriculants
10
+ 7.0%
(75 - 90)
1970
1975
1980
1985
1990
Assooation o! American Medical Colleges. Drvision ol Minority Health. Education and Preventior.
91
92
A former president of the National Medical
Association credits the 1954 Supreme Court decision to bar segregation in public schools in the
Brown v. Board of Education case, the Civil Rights
Act of 1964, the Voting Rights Act of 1965, and the
assassination of Dr. Martin Luther King, Jr., in
1968, as leading to an intensified public interest in
rectifying the past inequities in educational and
93 9 1
From 1975 to 1989, the proportion of minorities in the population increased by 18.5 percent
while the proportion in medical school increased by
�
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Title
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Health Care Reform
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2006-0810-F
Description
An account of the resource
<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
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Clinton Presidential Records
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William J. Clinton Presidential Library & Museum
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Workforce Briefing Book [1]
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Health Care Task Force
General Files
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2006-0810-F Segment 1
Is Part Of
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Box 49
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
Provenance
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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5/5/2015
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42-t-2194630-20060810F-Seg1-049-003-2015
12090749