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7 th Annual Physician Workforce Research Conference Physician Response to Economic Incentives

7 th Annual Physician Workforce Research Conference Physician Response to Economic Incentives. Adam Smith’s Invisible Handshake With Hippocrates D. Douglas Miller, MD, CM, MBA AAMC Robert G. Petersdorf Scholar. AAMC Petersdorf Project. Premise 1

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7 th Annual Physician Workforce Research Conference Physician Response to Economic Incentives

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  1. 7th Annual Physician Workforce Research ConferencePhysician Response to Economic Incentives Adam Smith’s Invisible Handshake With Hippocrates D. Douglas Miller, MD, CM, MBA AAMC Robert G. Petersdorf Scholar

  2. AAMC Petersdorf Project Premise 1 National and regional economies directly and indirectly affect medical student career decisions. Corollary 1 Significant economic downturns (i.e. recessions) create financial pressures that impair the physician workforce’s free market capacity to self-correct.

  3. AAMC Petersdorf Project Premise 2 Resourcing of state/provincial health care costs is critical to public medical education expansion & workforce balance. Corollary 2 Public resource contraction impacts household finances, and medical student ‘consumer ’decisions tied to tuition price, personal debt & future income.

  4. AAMC Petersdorf Project Premise 3 Publicly-financed national health care systems in which medical students clinically train affect their ultimate career decisions. Corollary 3 Different U.S. and Canadian health care delivery systems create different primary care workforces.

  5. The 1929 Depression & >15 Recessions

  6. “The Great Recession”– Economic Ground Zero

  7. The “Great Recession” of 2007-09 Impact Across the 49th Parallel United States Canada GDP Nadir-6.8% Stock Market Fall-52% Unemployment10.1% CCI Nadir25 Savings Rate8% -1.8% -48% 8.3% 54 1%

  8. USA Breaking From the Pack USA Canada

  9. I. U.S. and Canadian Economies (1980-2010) • For ~30 years, both national economies grew & diversified to comparable degrees. • After recessions, health care cost escalated transiently then plateau’d; post-2000 increases as % of GDP were comparable (U.S.=+27.2%, Canada=+28.5%). • 2007-09 “Great Recession” had a more severe impact on the U.S. economy, although ARRA permitted more U.S. personal savings and financial deleveraging. • 2000-01 “Dot.com” recession did not impact Canadian CCI. 2007-09 recession reduced Canadian personal savings rates to all time lows.

  10. National Health Care Policy Actions (1980-2010) TWO PATHWAYS TO   UNIVERSALITY >10 U.S.federal health care policies (MCR Secondary Payer Act, MCR PPS, COBRA, EMTALA, MCR Catastrophic Coverage Act, MCR RBRVS, HIPAA, BBA, SCHIP, MCR Rx Drug Act, PSQIA, ARRA, CHIPRA, ACA) 1Canadian federal health care policy (CHA), renewed by 2003 Ministers’ Health Care Accord CHA ACA Recessions

  11. II. U.S. and Canadian Health Policy (1980-2010) • >10-fold more U.S. federal health care policies enacted to address costs/gaps/access before 2010 ACA ‘universality’. • 2003 Canadian policy renewal of 1984 single-payer public insurance and federal funding commitments. • U.S. private sector co-insurance options and health insurance premiums grew incrementally from 1995-2003, achieving a ‘balanced’ market circa 2005. • Both countries face regional health & wealth disparities, but the U.S. has greater health care cost variability. • U.S. policy stakeholders & care delivery agents add complexity, threatening ACA implementation & system sustainability.

  12. U.S. GQ Primary Care Choices (1978-2010) 1978-1992 1998-2010 ?

  13. Primary Care Career Choices U.S. GQ (2001-2010) Canada CGQ (2001-2010)

  14. III. Graduate Profiles & Primary Care Career Choices (2001-2010) U.S. GQ Canada CGQ • Female = +2.7%; av. debt = +38% • After steady PC choice decline, sudden 2008-10 increase, mainly from internal medicine (IM) • Abrupt PC increases preceded both Dem. pro-universality policy reform efforts (Clinton 1990-93, Obama 2008-10); IM choices may reflect (mal-) adaptation to policy outcome uncertainties. • Female = +4.7%; av. debt = +32% • After stable PC choices, sudden 2009-10 increase, mainly from family medicine (FM) • Delayed (from 2003 policy renewal) 2009 FM increase tracked regional policy actions (i.e., a new North Ontario medical school, PC ‘teams’, better PC pay, etc.), and vested universal access to care role of FM.

  15. U.S. v MA GQ Primary Care Choices

  16. MA Primary Care Career Choices % Annual Variability % PC Change Histogram Kurtosis = 7.5 Skewness = 2 12

  17. IV. MA Policy Reform & MD Career Choice • Phase 1 (2005-07) & Phase 2 (2008-2010) MA health care policy reform increased the insured population (%, #). • MA PC choices paralleled the U.S. trend of sharp 2005-07 declines, and abrupt 2008-10 increases. • After 2005, annual variability in PC choices was greater in MA v U.S. (43±35% v 22±28%; p<0.005), with year-to-year variability ≥20% in 5/6 years in MA. • Dual pressures of state and national policy reforms may contribute to greater PC choice volatility, and lower GQ satisfaction with non-clinical educational domains in MA.

  18. Lagging & Leading Economic Indicators

  19. V. Career Choice Confidence • Occupational Alternatives Questionnaire (OAQ): • fell significantly in the 2009-10 NRMP match cycle; greater M declines were sustained into the 2010-11 cycle. • OAQ trended with lagging economic indicators (i.e., unemployment) > leading economic indicators (i.e., CCI)

  20. U.S. Graduate Career Choice Confidence OAQ v CCI Trends Gender OAQ Differences

  21. V. Career Choice Confidence • 19% of 2010-11 graduates answered “YES” to: “Did factors affecting the U.S. economy influence your specialty decision?” • “YES” respondents cited: • emotions (i.e., fear, pessimism, uncertainty, insecurity) • mental accounting for future income (i.e., salary, reimbursement, debt repayment capacity).

  22. Top 10 Themesfor “Yes” Responses:

  23. Top 10 Themes for “No” Responses:

  24. Medical Applicant Price Sensitivity Total Applications Average Tuition & Fees

  25. Medical Applicant Price Sensitivity U.S. Price Elasticity Canadian Price Elasticity

  26. Conclusions 1. In a severe economic recession, free market career choice tilts the physician workforce balance (i.e., PC versus specialists, and choices within PC). 2. Without government regulation &/or professional organization intervention, ‘bad economy’ career decisions reflect personal finances > public interests. 3. Health care policy fostering universal PC access &/or rewarding accountable care alters MS-4 career decisions: - in favor of perceived system needs (for FM in Canada), - in reaction to systemic uncertainties (to IM in U.S., MA).

  27. Conclusions (cont’d.) 4. 19% of 2010-11 graduates cited economic factors affecting their specialty decisions, with M>F career choice confidence erosion since 2009-10. 5. Medical school applicant elasticity to higher tuition: - ‘bearish’ demand occurred in U.S. & Canadian men from 2000-2002 - ‘bullish’ applicant supply occurred in Canada & the U.S. from 2007-09. Thanks to all my EDI, AAMC and AFMC colleagues

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