2017 HSC Section 2 - Practice Management

DISCUSSION

Physician Workforce Analysis and Reform

Physician workforce analysis and reform presents

extraordinary challenges. To begin to address these chal-

lenges, we need to know where we currently are in

terms of supply, demand, and infrastructure to deliver

these services. Although debate continues, most believe

that we currently have a gap between the supply of oto-

laryngologists and patient demand; it is further believed

that the underservice gap is increasing over time. There

is also agreement that our current health care infra-

structure is inadequate to meet current demand, and

even more inadequate if we consider the additional

demand of an aging population and the predicted effects

of the ACA.

Division exists on the size of this underservice gap

and how best to mitigate future deficiencies. In discus-

sions with otolaryngology leaders, Michael Maves MD,

MBA (past Executive Vice President of the AAO-HNS

and past Chief Executive Officer and Executive Vice

President of the AMA) believes the otolaryngology work-

force is markedly underserving current US need and

that this situation, under existing policy, will only wors-

en. “What is currently needed is a true snapshot of cur-

rent services to guide our future endeavors” (M. Maves,

personal communication, January 29, 2014).

David Kennedy, MD (former Chair of the AAO-HNS

PRC) believes that we, as a specialty, cannot afford to

wait for perfect data. He believes the data have been

derived from the most recognized sources and the prima-

ry issues are not the absolute numbers but whether the

current otolaryngologists to population ratio and the cur-

rent scope of practice are correct for the US health care

system. He is concerned that this ratio is decreasing,

especially in the face of an aging population, and is con-

cerned by the effect the ACA will have on that ratio. Evi-

dence from multiple data sources indicates that this

ratio has decreased and that this trend will continue.

“Under all scenarios, a shortage of otolaryngologists by

2025 is predicted, even allowing for the expectation that

mid-level providers will provide lower intensity services

within the specialty.”

He agrees that generational life-

style preferences, an aging workforce, payment changes,

and potential downstream effects of resident work hour

limitations are difficult to quantify, but certainly need to

be considered when future projections are prepared. He

also believes that this gap cannot be corrected by

increasing residency training alone, but that increase

should be coupled with changes to the structure of cur-

rent residency training through shortening the length of

training or earlier subspecialization.

Harold Pillsbury, MD (past President of the Triolog-

ical Society and the ABO) has grave concerns regarding

diluting our otolaryngology residency programs by

potentially developing a two-tiered residency or a prima-

ry certificate program. He notes that “funding for resi-

dents encompasses only five years or first certification.

It would be difficult to envision how we could support a

five year residency with the present paradigm of funding

from the Centers for Medicare and Medicaid Services.”

His second concern involves the present resident work-

force, in that “young people are emphasizing lifestyle

more than they did previously”. Additionally, regulations

on resident work hours have decreased productivity com-

pared to past generations.

Although debate exists, oth-

er authors have voiced concerns that decreasing resident

work hours can impact surgical training experience.

12–14

Dr. Pillsbury is also concerned that some forces within

our specialty tend to overestimate the size of our group

to increase our perceived political power on the federal

policy level. He believes this is short-sighted and only

serves to hurt our specialty by reducing our actual num-

bers and decreases our ability to train future residents.

Dr. Pillsbury agrees that the future supply of otolaryng-

ologists will be less than adequate and improvements in

technology and surgical applications will only increase

demand and make this shortage more acute (H. Pills-

bury, personal communication, February 3, 2014). To

highlight the importance of these issues, the National

Ambulatory Medical Care Survey added a set of ques-

tions examining physician workforce issues in 2013.

“Fueled in part by changes in the delivery system, there

is strong interest in understanding the dynamics of prac-

tice redesign and how team-based medical care is actual-

ly delivered.”

National workforce study databases project future

supply and demand for physicians, and most conclude

that there is currently a shortage of physicians in the

United States and also conclude that the deficiency is

increasing. Factors cited that exacerbate this shortage

include increased population growth, an aging popula-

tion, and economic and health policy factors. This issue

is made more complex by changes in physician demo-

graphics, trends in retirement, and medical student and

resident training capacity. An additional unknown is

what the future role and scope of nonphysician health

care providers such as advanced practice registered

nurses and physician assistants (PAs) will be.

Physician workforce analysis and reform are chal-

lenging. Political, socioeconomic, and physician autono-

my issues all interact to complicate the discussion of

what represents the optimal or even an adequate physi-

cian workforce. Questions pertaining to what is a full-

time practice and what constitutes a part-time practice,

comparisons of academic and private practices, male as

opposed to female physician lifetime productivity, and

the perceived generalist–specialist imbalance

all polar-

ize the debate. The major focus of workforce reforms

should be to optimize the training of the future work-

force within any given specialty and guide leaders to

increase emphasis on areas for which more background

and training are warranted and create policies to incen-

tivize a more optimal distribution of care.

The US health care system, with the passage of the

ACA, is evolving at an increasingly rapid pace. In gener-

al, the structure of health care delivery is moving

toward larger and more integrated systems. The tradi-

tional independent physician’s practice is being replaced

by contractual arrangements among hospitals or large

groups of clinicians. The financing of medical care is

changing due to federal legislation, meaningful use, and

Laryngoscope 126: October 2016

Hughes et al.: Otolaryngology Workforce Analysis