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Journal of ASPR - Spring 2012 - Healthcare Resources: Trends Worth Watching
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Healthcare Resources: Trends Worth Watching

American Medical Association, 2012. Reprinted by permission of the publisher

It takes a healthcare team—physicians, nurses and other healthcare professionals—to deliver optimal patient care. When there are shortages in the healthcare team, delivering quality care becomes more challenging. Concern about the lack of a systematic healthcare work force planning mechanism is intensifying. The dynamics of the physician workforce, in particular, are complex, and the risk of an imbalance between physician supply and demand is growing. Shortages of certain physician specialties are severe in some areas, and increasing shortages of nurses and other health care professionals further exacerbate the problem. Due to the length of training required for graduate medical education, a quick resolution to this problem is unlikely; thus, the patient’s ability to receive safe, high-quality care may be jeopardized.


  • Of the total number of US physicians in 2009 (972,376 physicians), 15 percent were under 35 years of age; 22 percent were between the ages of 35 and 44; more than one-fifth of physicians (22.8 percent) were ages 45 to 54; nearly one-fifth of all physicians (19.5 percent) were 55 to 64 years of age, and 20.7 percent were age 65 or older.1
  • With the exclusion of obstetricians/gynecologists and primary care physician (PCP) subspecialties, PCPs comprised 39.4 percent of all active US physicians in 1975 and 36.2 percent in 2009. In 2009, international medical graduates (IMGs) comprised more than 30 percent of the workforce in primary care specialties.2
  • At the end of 2009, three-fifths of physicians (58.9 percent or 572,289) were in the following 10 specialty fields: internal medicine, family medicine, pediatrics, obstetrics/gynecology, anesthesiology, psychiatry, general surgery, emergency medicine, diagnostic radiology, and orthopedic surgery.3
  • In 2009, more than half (55 percent) of all physicians were located in 10 states: California, New York, Texas, Florida, Pennsylvania, Illinois, Ohio, Massachusetts, New Jersey and Michigan.4
  • In 2009, 374 metropolitan statistical areas contained 92.2 percent of the total physician population and 95 percent of all physicians in hospital-based practice, which reflects the clustering of interns, residents, fellows and full-time staff in large metropolitan and university-affiliated teaching hospitals.5
  • By 2025, the United States will face a 27 percent shortage of adult generalist physicians. Even with increased supply via the expansion of residency programs, demand for primary care services will exceed the supply of providers.6
  • According to a recent study by economists from Dartmouth College, the National Bureau of Economic Research, the Congressional Budget Office and Vanderbilt University, a steady decrease in the number of hours worked per week was observed for all physicians during the past decade.7
  • According to statistics recently released by the Association of American Medical Colleges, first-time medical school applicants reached an all-time high of 32,654 in 2011, a 2.6 percent increase from 2010. Total medical school applicants increased by 2.8 percent to 43,919. However, the nation still faces a significant shortage of physicians.8

Physician practice settings and models of care

  • There is a growing movement, especially among young physicians, to choose the hospital employee model of practice.9 Increasing shares of young physicians burdened by medical school debts and seeking a regular work schedule are deciding against opening private practices. Instead, they are accepting salaries at hospitals and health systems.10 The number of physicians who leave private practice to become hospital employees has increased from 22 percent to almost 50 percent in the last five years.11 According to 2010 data released by the Medical Group Management Association (MGMA), 65 percent of established physicians and 49 percent of those finishing residencies landed positions in hospital-based practices in 2009.12
  • The MGMA reports that more than 66 percent of medical practices were physician-owned as recently as 2005; however, within three years, that share dropped below 50 percent, and analysts predict the slide will continue.13
  • At some point in 2008, an estimated 36 percent of US physicians worked locum tenens in primarily rural areas—up from 30 percent in 2003.14 Primary care remains the key source of demand for locums tenens physicians, with the hospitalist, anesthesia and behavioral health sectors not far behind.15
  • According to the Society for Innovative Medical Practice Design, there were about 5,000 concierge physicians in the United States in 2009.16
  • Consumer Operated and Oriented Plan (CO-OP) programs will foster the creation of qualified nonprofit health insurance issuers to offer competitive health plans in the individual and small group markets.17 The Affordable Care Act (ACA) has authorized the expenditures of $3.8 billion in loans to establish CO-OP programs that focus on integrated care and greater plan accountability.18

Physician career satisfaction

A study examining the relationship between health information technology (IT) and physician career satisfaction,19 which could potentially reduce physician burnout and attrition, demonstrated the following results:

  • Physicians who used five to six types of health IT were more likely than physicians who used zero to two types of health IT to be “very satisfied” with their careers.
  • Information technology usages for communicating with other physicians and emailing patients were positively associated with career satisfaction.
  • Primary care physicians who used technology to write prescriptions were less likely to report career satisfaction, and specialists who wrote notes using technology were less likely to report career satisfaction. Physicians often perceive these activities as adding additional burdens to their workload. These findings suggest that the health IT packages available for these activities are not adequate for physicians’ needs or that physicians require more training or time to adapt to these new technologies.

A new report from the market research firm Kalorama Information estimates the worldwide market for medical mobile applications hit $84.1 million in 2010, more than double the $41 million market in 2009. Medical applications in 2009 comprised 1.5 percent of the total mobile application market. In the United States, 35 to 40 percent of physicians used a PDA or smartphone in 2008, and that number topped 50 percent in 2010.20

Supply of non-physician providers

With more than 3.1 million registered nurses (RNs), nursing is the largest health care profession in the United States.21 With the average age of RNs projected to be 44.5 years by 2012, nurses in their 50s are expected to become the largest segment of the nursing work force, accounting for nearly one-quarter of the RN population.22 Of all licensed RNs, 2.6 million, or 84.8 percent, are employed in nursing; consequently, about 500,000 licensed nurses do not work in the nursing field but potentially could do so.23

According to the American Association of Colleges of Nursing, there was a 5.7 percent enrollment increase in entry-level baccalaureate programs in nursing in 2010; however, this increase is not sufficient to meet the projected demand for nursing services.24 Current projections for 2025 indicate a shortage of 260,000 registered nurses. A shortage of this magnitude would be twice as large as any nursing shortage experienced in this country since the mid-1960s.25

Non-physician providers scope of practice

A recent New York Times article provided some insight on the rising number of nurses who are calling themselves “doctors.” As the demand for healthcare services has grown, physicians are no longer the sole gatekeepers for their patients’ entry into the system. Teamwork is the new mantra of medicine, and nurse practitioners (NPs) and physician assistants (PAs)—sometimes known as mid-levels or physician extenders—have become increasingly important care providers, particularly in rural areas.26

The role of ancillary providers is likely to increase in future years. The ACA contains several provisions affecting the likely future supply of NPs, PAs and certified nurse midwives (CNMs). Specifically, these provisions include a 15 percent carve-out for PA educational programs in the funding for primary care medicine, making PA educational programs eligible for faculty, loan-repayment grants and grants for authorized nurse-midwifery education programs. Such incentives are likely to increase the supply of certain ancillary providers. The supply of these practitioners may, in turn, affect the types of practices that use NPs, PAs and CNMs.27

In 2009 nearly four-fifths (79.9 percent) of primary care physicians in large practices (11 or more physicians) often worked with ancillary caregivers, compared with only 65 percent of medium-size practices (three to 10 physicians) and 37.8 percent of small practices (one to two physicians). Only 31.3 percent of solo practice physicians worked with NPs, PAs or CNMs.

Physicians in practices with more revenue from Medicare (45.4 percent) were less likely than those in practices with less revenue from Medicare (52.3 percent) to work with ancillary providers. Conversely, physicians in practices with more revenue from Medicaid (53 percent) were more likely than those with less revenue from Medicaid (45.2 percent) to work with ancillary providers.

Hospitals and healthcare facilities

Hospitals continue to employ physicians in greater numbers. More than half (56 percent) of Merritt Hawkins physician search assignments in 2010/2011 featured hospital employment of physicians, up from 51 percent the previous year and up from 23 percent in 2005/2006. Hospitals are seeking to align with physicians in response to healthcare reform, which is promoting the use of ACOs, bundled payments and other physician-aligned and integrated delivery mechanisms.28

According to a recent PricewaterhouseCoopers’ report, more physicians are aligning with hospitals for financial security, improved work-life balance, relief from growing administrative burdens, access to health information technology and incentives to improve health outcomes and patient care coordination, and opportunities to participate in new payment arrangements such as shared-savings.29

Predicted impacts for patients

  • Patients will experience reduced access to primary care physicians due to growing shortages.
  • Patients will need assistance differentiating between physicians and independent non-physician providers and choosing between them when selecting the appropriate site of care.
  • Technology will enable patients to take a more active role in their care and to have access to home-monitoring devices.
  • Given that CO-OP profits must be used to lower premiums, enhance benefits or improve health care quality for enrollees, these programs may increase patient opportunity to access lower-cost, high-quality healthcare.
  • Changes in physician practice patterns will result in patients being seen by several different physicians and practitioners, especially in a hospital setting. These changes will precipitate decreased continuity of care and alter the patient-physician relationship.

Predicted impacts for physicians

  • Increasingly fewer physician work hours resulting from economic factors, such as lower fees and increasing market pressure, may further frustrate the goals of health reform. This may require an expanding physician work force to take on new roles and enhanced functions in a reformed delivery system.
  • Current trends predict that the physician work force of the future will be predominantly young, increasingly female, with higher numbers of IMGs.
  • An increasing number of physicians will seek a balanced lifestyle, options for working part-time or job-sharing, and may take leave from active practice from time to time with an attendant need to seek re-entry.
  • Medical student loan debt, liability reform, Maintenance of Certification/Maintenance of Licensure (MOC/MOL) and scope of practice will continue to be the most pressing issues for young physicians.
  • The online-care model will free up physicians to see patients and consult with other physicians regardless of their location, such as in rural or underserved areas, and can offer a unique way to control the physician’s schedule.
  • Physician work force shortages may cause additional emphasis to be placed on the role of non-physician providers—nurse practitioners, physician assistants and certified nurse midwives.
  • In the future most physicians may be compelled to consolidate with other practitioners, become hospital employees, or align with large hospitals and health systems for capital and administrative and technical resources.
  • For large physician groups seeking to form a CO-OP, consideration will need to be given to future contract negotiations with health insurers and antitrust and tax-exemption compliance; however, CO-OPs provide rewards for delivering high-quality, cost-effective care and strengthen the patient-physician relationship by removing the intermediary between providers and patients.

Predicted impacts for hospitals and healthcare facilities

  • The future practice model will become increasingly dependent on relationships with hospitals and will vary by region. ACOs, private practice medical homes, large independent practice associations, community health centers, concierge practices and small-aligned groups may proliferate.
  • Healthcare organizations working in conjunction with physicians will explore ways to integrate multiple forms of health IT into practice.
  • Emerging technologies will result in physicians being less tethered to the hospital and able to perform more procedures in the office.
  • Complexity in the changing healthcare landscape may result in hospitals enhancing expertise and boosting patient volumes and revenues in high-growth service lines.
  • The trend of physician employment will require that hospitals adjust their recruitment and retention methods, especially in growing service lines, such as cardiovascular care, orthopedics, cancer care and radiology.


  1. American Medical Association Division of Survey and Data Resources, “Physician Characteristics and Distribution, 2011 Edition,” Division of Survey and Data Resources. Available at AMA, Accessed May 26, 2011.
  2. AMA Market Research, “Survey of IMG Physicians.” AMA Web site, Accessed October 22, 2009.
  3. American Medical Association Division of Survey and Data Resources, “Physician Characteristics and Distribution, 2011 Edition,” Division of Survey and Data Resources. Available at AMA, Accessed May 26, 2011.
  4. Ibid.
  5. Ibid.
  6. Scheffler R., “Recruiting the Docs We Need,” Modern Healthcare, 2009; 39(4): 24, PubMed Web site, Accessed December 27, 2010.
  7. Staiger D, “Trends in the Work Hours of Physicians in the United States,” JAMA, February 24, 2010-Vol 303, No.8, JAMA Web site, Accessed August 15, 2011.
  8. Trapp D, “Health care workforce report questions how to plan for the future,” American Medical News Web site, Accessed October 31, 2011.
  9. Ibid.
  10. Cantlupe J, “Hospitalists Seek Parity with Hospitals,” HealthLeaders Media Web site, Accessed December 16, 2010.
  11. Mc Daniel J, “Physician Employment Trends,” MedInnovation Web site, Accessed April 13, 2010.
  12. Stagg Elliott, V, “Small practices: Adapting to survive,” American Medical News Web site, Accessed July 19, 2011.
  13. Ibid.
  14. “Locum Tenens: Lifestyle, Opportunities Attracting More Physicians,” New England Journal of Medicine Career Center Web site, Accessed January 30, 2011.
  15. Ibid.
  16., “Buy your own doctor,” Web site, Accessed January 30, 2011.
  17. US Department of Health and Human Services (DHHS). “Consumer Operated and Oriented Plan Program.” Washington, DC: Centers for Medicare and Medicaid Services (CMS); CMS Web site, Accessed October 6, 2011.
  18. “ACOs, CO-OPs and other Options: A ‘How-To’ Manual for Physicians Navigating a Post-Health Reform World.” AMA Web site, Accessed October 6, 2011.
  19. Elder K, et al. “Health Information Technology and Physician Career Satisfaction,” Online Research Journal: Perspectives in Health Information Management, PubMed Central Web site, Accessed May 25, 2011.
  20. Merrill M, “Kalorama: Medical Mobile App Market Worth $84.1 M,” Healthcare IT News Web site, Accessed January 30, 2011.
  21. Ibid.
  22. Rosseter R, “Nursing Shortage Fact Sheet,” American Association of Colleges of Nursing Web site, Accessed July 30, 2011.
  23. AMN Healthcare, “2011 Survey of Registered Nurses: Job Satisfaction and Career Plans,” AMN Healthcare Web site, Accessed July 18, 2011.
  24. Ibid.
  25. Ibid.
  26. Harris G. “When the Nurse Wants to be called Doctor,” New York Times Web site, Assessed October 3, 2011.
  27. Park M, et al., “Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants in Physician Offices,” National Center for Health Statistics Web site, Accessed September 5, 2011.
  28. “2011Review of Physician Recruiting Incentives”, Merritt Hawkins Web site, Accessed June 14, 2011.
  29. “From Courtship to Marriage: Why Health Reform is Driving Physicians and Hospitals Closer Together,” PricewaterhouseCoopers Health Research Institute Web site, Access April 6, 2011.

Editor’s Note:

The preceding article was submitted to JASPR by the American Medical Association. This article is a compilation of healthcare trends along with predictions of what the AMA and its Council on Long Range Planning and Development are forecasting for the future. Visit to view more detailed information or download additional chapters in this series or learn more about activities of the AMA and its Council on Long Range Planning and Development.

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Journal of ASPR - Spring 2012

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