I
III
II
I
I
I
Developing a rational national health manpower policy The concern about the numbers, types, and distribution of America's physicians is becoming an increasingly important element in national health policy debate. There is a growing realization that the massive program of federal subsidization of medical education has, if anything, been perhaps too successful and that, instead of a shortage which previously existed, this country will soon be faced with a substantial surplus of physicians of all types. There is also an increasing awareness of the fact that the creation of a surplus does not necessarily correct one of the major difficulties, that of maldistribution, which remains a matter of continuing concern. 1,2 Of more immediate significance to health policy planners, however, is the realization that for each new physician available there is an increase in the demand for costly medical services, some of which might not have been engendered in a situation in which more ready access was unavailable. There is much debate about how much this actually increases health care costs, but probably the effect is substantial. 3 Furthermore, in circumstances in which a physician surplus exists, there is a belief that this leads to additional escalation of health care costs through ovemtilization of technology and unnecessary services. For a government already financially overcommitted to support health care, increasing costs for any reason are intolerable, although there is no clear rationale for the belief that health care costs should not continue to consume an increasingly larger share of the gross national product if the public does, in fact, want to spend its income for the best possible medical care. Nevertheless, the bureaucratic mind-set has decreed that rationing of services shall exist and has tried to disguise this policy under a host of peripheral programs, such as the Professional Standards Review Organization (PSRO), health planning area initiatives, Health Maintenance Or0190-9622179/050457+03500.30/0 © 1979 Am Acad Dermatol
ganization subsidization, prospective reimbursement, and cost containment legislation. Federal efforts directed toward stemming the tide of physicians have been to date relatively limited in scope, consisting for the most part of restrictions on use of foreign medical graduates and a gradual reduction in the subsidization of graduate medical education. Some states such as California are taking more stringent measures to reduce the flow of certain specialists to areas of perceived oversupply. Unfortunately, health manpower needs analysis is still in a relatively primitive state, and the data necessary to make important health manpower decisions are often highly imprecise or simply unavailable. Of all specialties to date, dermatology has addressed this issue in the most careful and sophisticated analytical way, and yet it is fair to say that those of us who have dealt with this issue for over 8 years are unable at this juncture to predict our future specialty needs with any degree of confidence. This is in large measure a reflection of the fact that health manpower needs will, in the final analysis, relate more closely to the type of health care financing which is ultimately adopted, important changes in health care technology and scientific advances, and improved productivity, none of which are currently predictable. Even our data base, which far exceeds that of most other specialties, has serious flaws that are becoming increasingly apparent and that should force us to be cautious in our estimates. Clearly anecdotal evidence at this time would force us to conclude that in some of the areas of the country, particularly in the larger metropolitan areas and some of the regions surrounding the medical schools with long-standing dermatology residency training programs, there is now, or will soon be, a significant oversupply of dermatologists. Response to these signals has been far from 457
458
Weao'
uniform to date. FortunateIy, we have created at least one successful mechanism by way of the dermatology manpower maps, now in their second issue, which have already proved successful in promoting more equitable distribution of dermatologists and which hopefully will become increasingly important in promoting voluntary distribution of dermatologists to areas of perceived undersupply. In this sense, we are again far ahead of all other specialties in this critical area. Two recent developments reflect the increasing national concern about whether, and how, there should be created a national policy with respect to how many specialists of each type we shouId train and how to achieve better distribution. The first of these efforts is the creation by the Congress of the HEW-based Graduate Medical Education National Advisory Committee (GMENAC). 4 This committee is charged with analysis of health manpower needs on a specialty-by-specialty basis, and dermatology is the second specialty to be subjected to its scrutiny. For dermatology, a panel was appointed of which dermatologists comprise a substantial segment but not a majority. Utilizing the so-called Delphian approach, each panel will attempt to analyze what proportion of the major diseases appropriate to that specialty should be seen by the specialist and what proportion can be adequately handled by other physicians. The Delphian approach is a process whereby a group of knowledgeable individuals of diverse backgrounds will discuss, and seek to reach a consensus, conceming issues about which precise information is not available. The GMENAC dermatology panel was specifically requested to analyze the thirty most common skin diseases and to estimate the approximate percentage of patients who fall into various categories of relative complexity of these diseases and the perceived capabilities of different types of specialists to deal effectively with each category. In addition, the question of delegability of certain services to physician extenders is a major emphasis of the GMENAC approach. The report on dermatology is now in its final phases of completion and hopefully will accurately reflect the recommendations of what has been a truly outstanding panel. The thoughtful and cautious approach of the three dermatologist panelists was
Journal of the American Academy of Dermatology
particularly gratifying to those of us permitted to observe the deliberations. A second major initiative has been recently undertaken by the Association of American Medical Colleges, which appointed a task force on graduate medical education, of which one working group was designated to address the issue of specialty distribution. This group, chaired by Dr. Theodore Cooper, the former assistant secretary for health, HEW, and currently provost at Cornell University, has developed a final report which will be submitted for review by the association this fall. While it is unfair to predict precisely how the final document will approach the problems, one major current recommendation is to leave the specialty mix to individual medical institutions that have training programs. The practicality of this remains to be evaluated. What then might be a rational national health manpower policy, recognizing that all predictions are inherently highly imprecise at this time and in the foreseeable future? There would appear to be one approach which avoids the leap-before-youlook consequences and yet does not rely on inaction or complacency, which might prove to be equally inappropriate. This approach could most appropriately be termed anticipatory capacity expansion (ACE). To better understand the rationale for this concept it might be appropriate to present an analogy. One concept as to why the allies eventually won World War II was that the elasticity and expansion capability of the industrial capacity of the United States far exceeded that of all other countries; thus the available resources were significantly greater than those of the enemy, whose industrial capacity was already at a maximum. There are those who would contend that had the allies exercised these expansion capabilities sooner, a victorious outcome might have been observed far more quickly, but, even so, the capacity was there and was able to respond when called upon to do so. Rather than trying to second-guess the future manpower needs on a specialty-by-specialty basis, it would seem to be more rational for us to examine carefully the rate-limiting factors that would impede a rapid response to an obvious need for a change in the supply of various types of special-
Volume 1 Number 5 November, 1979
ists. Based upon this information, we should then institute programs that would provide the capacity and flexibility to expand the output in the shortest possible period of time or, conversely, to constrict the output, if necessary, with the least disruption to the system. Thus, rather than churning out possibly unwanted specialists or reducing the supply below that required on the basis of imprecise estimates, we would have created a system with maxi m u m flexibility and the shortest possible leadtime, if called upon to respond. To restructure our present system in this way would be far less costly, both in a financial sense and also in terms of protecting the public from the consequences of either over- or undersupply, than if we were to proceed arbitrarily to respond now to future perceived needs which predictably will be based on imprecise information. If we transpose this ACE approach to our own specialty, it is obvious that the expansion potential is readily available by virtue of the fact that there are already over forty schools of medicine with no residency training program or full-time departments or divisions of dermatology. Presumably, all of these could become loci for future training of dermatologists, if necessary. However, to suppose that such expansion could take place quickly is fallacious because the resources in terms of faculty, space, and teaching resources are inadequate and for the most part nonexistent. Thus, a response would be painfully slow and needlessly stressful. In other words, the lead-time is too protracted. For dermatology, the rate-limiting factors are financial support and faculty, both of which are mutually interdependent. Were we to convince those who dispense federal and state support funds that this ACE approach is desirable, it would seem feasible to consider expanding our educational capacity gradually but with deliberate speed by establishing
Health manpower policy
459
full-time faculty in schools which currently do n o t have any programs (three individuals per school to create a critical mass). These programs would b e exhorted to remain indefinitely without residency programs, unless the need for such becomes clearly apparent, but would be abIe to provide consultative services, to engage in research, a n d , most importantly of all, to teach and train students and primary care physicians in necessary d e r matologic skills. It is important to recognize that this will a l s o require increased support and faculty for t h o s e existing training programs from whose programs the faculty to staff these new programs would in large measure be recruited. Any program w h i c h does not address this basic requirement will be a n exercise in futility. While the above recommendations will not b e easy to promote or to accomplish, this ACE approach provides the most sensible one for future national health manpower policy.
Peyton E. Weary, M.D. Charlottesville, VA REFERENCES i. A report to the President and Congress on the status of health professions personnel in the United States, Bureau of Health Manpower, Health Resources Administration, U.S. Department of Health, Education and Weffare (PHEW Publication No. (HRA) 78-93, August, 1978). 2. Report of the 1976 National Conference on Health M a n power Distribution, National Health Council, Inc., New York, June, 1976. 3. Sloan FA, Fetdman R: Competition among physicians. Proceedings of a conference on competition in the health care secta: Past, present, and future. Sponsored by the Bureau of Economics, Federal Trade Commission, March, 1978. 4. Interim report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health, Education and Welfare, Office of Graduate Medical Education, Health Resources Administration, April, 1979.
III
II
I
I
I
Developing a rational national health manpower policy The concern about the numbers, types, and distribution of America's physicians is becoming an increasingly important element in national health policy debate. There is a growing realization that the massive program of federal subsidization of medical education has, if anything, been perhaps too successful and that, instead of a shortage which previously existed, this country will soon be faced with a substantial surplus of physicians of all types. There is also an increasing awareness of the fact that the creation of a surplus does not necessarily correct one of the major difficulties, that of maldistribution, which remains a matter of continuing concern. 1,2 Of more immediate significance to health policy planners, however, is the realization that for each new physician available there is an increase in the demand for costly medical services, some of which might not have been engendered in a situation in which more ready access was unavailable. There is much debate about how much this actually increases health care costs, but probably the effect is substantial. 3 Furthermore, in circumstances in which a physician surplus exists, there is a belief that this leads to additional escalation of health care costs through ovemtilization of technology and unnecessary services. For a government already financially overcommitted to support health care, increasing costs for any reason are intolerable, although there is no clear rationale for the belief that health care costs should not continue to consume an increasingly larger share of the gross national product if the public does, in fact, want to spend its income for the best possible medical care. Nevertheless, the bureaucratic mind-set has decreed that rationing of services shall exist and has tried to disguise this policy under a host of peripheral programs, such as the Professional Standards Review Organization (PSRO), health planning area initiatives, Health Maintenance Or0190-9622179/050457+03500.30/0 © 1979 Am Acad Dermatol
ganization subsidization, prospective reimbursement, and cost containment legislation. Federal efforts directed toward stemming the tide of physicians have been to date relatively limited in scope, consisting for the most part of restrictions on use of foreign medical graduates and a gradual reduction in the subsidization of graduate medical education. Some states such as California are taking more stringent measures to reduce the flow of certain specialists to areas of perceived oversupply. Unfortunately, health manpower needs analysis is still in a relatively primitive state, and the data necessary to make important health manpower decisions are often highly imprecise or simply unavailable. Of all specialties to date, dermatology has addressed this issue in the most careful and sophisticated analytical way, and yet it is fair to say that those of us who have dealt with this issue for over 8 years are unable at this juncture to predict our future specialty needs with any degree of confidence. This is in large measure a reflection of the fact that health manpower needs will, in the final analysis, relate more closely to the type of health care financing which is ultimately adopted, important changes in health care technology and scientific advances, and improved productivity, none of which are currently predictable. Even our data base, which far exceeds that of most other specialties, has serious flaws that are becoming increasingly apparent and that should force us to be cautious in our estimates. Clearly anecdotal evidence at this time would force us to conclude that in some of the areas of the country, particularly in the larger metropolitan areas and some of the regions surrounding the medical schools with long-standing dermatology residency training programs, there is now, or will soon be, a significant oversupply of dermatologists. Response to these signals has been far from 457
458
Weao'
uniform to date. FortunateIy, we have created at least one successful mechanism by way of the dermatology manpower maps, now in their second issue, which have already proved successful in promoting more equitable distribution of dermatologists and which hopefully will become increasingly important in promoting voluntary distribution of dermatologists to areas of perceived undersupply. In this sense, we are again far ahead of all other specialties in this critical area. Two recent developments reflect the increasing national concern about whether, and how, there should be created a national policy with respect to how many specialists of each type we shouId train and how to achieve better distribution. The first of these efforts is the creation by the Congress of the HEW-based Graduate Medical Education National Advisory Committee (GMENAC). 4 This committee is charged with analysis of health manpower needs on a specialty-by-specialty basis, and dermatology is the second specialty to be subjected to its scrutiny. For dermatology, a panel was appointed of which dermatologists comprise a substantial segment but not a majority. Utilizing the so-called Delphian approach, each panel will attempt to analyze what proportion of the major diseases appropriate to that specialty should be seen by the specialist and what proportion can be adequately handled by other physicians. The Delphian approach is a process whereby a group of knowledgeable individuals of diverse backgrounds will discuss, and seek to reach a consensus, conceming issues about which precise information is not available. The GMENAC dermatology panel was specifically requested to analyze the thirty most common skin diseases and to estimate the approximate percentage of patients who fall into various categories of relative complexity of these diseases and the perceived capabilities of different types of specialists to deal effectively with each category. In addition, the question of delegability of certain services to physician extenders is a major emphasis of the GMENAC approach. The report on dermatology is now in its final phases of completion and hopefully will accurately reflect the recommendations of what has been a truly outstanding panel. The thoughtful and cautious approach of the three dermatologist panelists was
Journal of the American Academy of Dermatology
particularly gratifying to those of us permitted to observe the deliberations. A second major initiative has been recently undertaken by the Association of American Medical Colleges, which appointed a task force on graduate medical education, of which one working group was designated to address the issue of specialty distribution. This group, chaired by Dr. Theodore Cooper, the former assistant secretary for health, HEW, and currently provost at Cornell University, has developed a final report which will be submitted for review by the association this fall. While it is unfair to predict precisely how the final document will approach the problems, one major current recommendation is to leave the specialty mix to individual medical institutions that have training programs. The practicality of this remains to be evaluated. What then might be a rational national health manpower policy, recognizing that all predictions are inherently highly imprecise at this time and in the foreseeable future? There would appear to be one approach which avoids the leap-before-youlook consequences and yet does not rely on inaction or complacency, which might prove to be equally inappropriate. This approach could most appropriately be termed anticipatory capacity expansion (ACE). To better understand the rationale for this concept it might be appropriate to present an analogy. One concept as to why the allies eventually won World War II was that the elasticity and expansion capability of the industrial capacity of the United States far exceeded that of all other countries; thus the available resources were significantly greater than those of the enemy, whose industrial capacity was already at a maximum. There are those who would contend that had the allies exercised these expansion capabilities sooner, a victorious outcome might have been observed far more quickly, but, even so, the capacity was there and was able to respond when called upon to do so. Rather than trying to second-guess the future manpower needs on a specialty-by-specialty basis, it would seem to be more rational for us to examine carefully the rate-limiting factors that would impede a rapid response to an obvious need for a change in the supply of various types of special-
Volume 1 Number 5 November, 1979
ists. Based upon this information, we should then institute programs that would provide the capacity and flexibility to expand the output in the shortest possible period of time or, conversely, to constrict the output, if necessary, with the least disruption to the system. Thus, rather than churning out possibly unwanted specialists or reducing the supply below that required on the basis of imprecise estimates, we would have created a system with maxi m u m flexibility and the shortest possible leadtime, if called upon to respond. To restructure our present system in this way would be far less costly, both in a financial sense and also in terms of protecting the public from the consequences of either over- or undersupply, than if we were to proceed arbitrarily to respond now to future perceived needs which predictably will be based on imprecise information. If we transpose this ACE approach to our own specialty, it is obvious that the expansion potential is readily available by virtue of the fact that there are already over forty schools of medicine with no residency training program or full-time departments or divisions of dermatology. Presumably, all of these could become loci for future training of dermatologists, if necessary. However, to suppose that such expansion could take place quickly is fallacious because the resources in terms of faculty, space, and teaching resources are inadequate and for the most part nonexistent. Thus, a response would be painfully slow and needlessly stressful. In other words, the lead-time is too protracted. For dermatology, the rate-limiting factors are financial support and faculty, both of which are mutually interdependent. Were we to convince those who dispense federal and state support funds that this ACE approach is desirable, it would seem feasible to consider expanding our educational capacity gradually but with deliberate speed by establishing
Health manpower policy
459
full-time faculty in schools which currently do n o t have any programs (three individuals per school to create a critical mass). These programs would b e exhorted to remain indefinitely without residency programs, unless the need for such becomes clearly apparent, but would be abIe to provide consultative services, to engage in research, a n d , most importantly of all, to teach and train students and primary care physicians in necessary d e r matologic skills. It is important to recognize that this will a l s o require increased support and faculty for t h o s e existing training programs from whose programs the faculty to staff these new programs would in large measure be recruited. Any program w h i c h does not address this basic requirement will be a n exercise in futility. While the above recommendations will not b e easy to promote or to accomplish, this ACE approach provides the most sensible one for future national health manpower policy.
Peyton E. Weary, M.D. Charlottesville, VA REFERENCES i. A report to the President and Congress on the status of health professions personnel in the United States, Bureau of Health Manpower, Health Resources Administration, U.S. Department of Health, Education and Weffare (PHEW Publication No. (HRA) 78-93, August, 1978). 2. Report of the 1976 National Conference on Health M a n power Distribution, National Health Council, Inc., New York, June, 1976. 3. Sloan FA, Fetdman R: Competition among physicians. Proceedings of a conference on competition in the health care secta: Past, present, and future. Sponsored by the Bureau of Economics, Federal Trade Commission, March, 1978. 4. Interim report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health, Education and Welfare, Office of Graduate Medical Education, Health Resources Administration, April, 1979.
