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P E R S P E C T I V E :
P G P S T A F F I N G
W E B E X C L U S I V E
4 February 2004
The Changing Shape Of The Physician Workforce
In Prepaid Group Practice
A Kaiser Permanente insider reflects
on the reasons for Kaiser’s staffing patterns,
which differ from the prevailing U.S. trend.
By Francis J. Crosson
ABSTRACT:
Multiple factors have combined to change the size and specialty composition
of the physician workforce in the nation’s largest prepaid group practices
over the past two decades. An examination of these changes can shed some light
on the past and potential future impact that changes in medical technology are
likely to have on the physician workforce of these organizations and the greater
physician community.
The physician workforce in the nation’s largest and oldest prepaid group
practices (PGPs) has changed in the past twenty years and will continue to do
so. With his current and previous papers, Jonathan Weiner has provided a nearly
twenty-year perspective on the changes that have taken place in the size and
specialty distribution of the physician workforce in those organizations.1
Many of the data in both papers are derived from an analysis of the Permanente
Medical Groups. Although other organizations are included in each study, Weiner’s
trend analysis, presented in the current paper, is focused on these Kaiser Perma-nente
PGPs and is therefore the core of this discussion.
It is in this analysis of workforce staffing trends at Kaiser Permanente, compared
with national physician workforce data, that the most interesting findings appear.
The first is that between 1983 and 2001, Kaiser Permanente PGPs have continued
to operate with a physician-to-population ratio that appears to be one-third
lower than the national ratio. The second is that during the same two-decade
period, dramatic change took place in the specialty distribution within those
same PGPs. Both findings require further analysis and discussion to determine
what implications, if any, either should have for future national workforce
planning.
Workforce
Size Comparisons
As described in Weiner’s previous paper, in 1983 the national physician
workforce staffing level was 170 full-time physicians per 100,000 population.
The figure for Kaiser Permanente PGPs was 111 physician full-time equivalents
(FTEs) per 100,000, 35 percent lower than the national level. By 2001 the national
figure had risen to 229 full-time physicians per 100,000, and Kaiser Permanente
PGP staffing had risen to 139 FTEs per 100,000, now 41 percent lower than the
national level. Thus, it would appear that the dramatic staffing difference
between PGP and the U.S. level, described in Weiner’s previous paper, not
only has persisted through two decades but has grown larger.
The question must be, “What combination of factors could account for such
a striking difference over a two-decade period?” As an active physician-executive
in Kaiser Permanente during that entire time, and despite considerable pride
in the efficiency of our delivery system, I find the difference difficult to
explain fully. Weiner’s data have been adjusted for a number of factors,
including patient/member demographics, the extent to which non-PGP-employed
physicians provide covered services, and the proportion of providers’ time
spent on patients who are not enrolled with the PGP. Other confounding variables
were considered. None of these adjustments or considerations materially affected
the large difference in apparent workforce size between Kaiser Permanente PGPs
and the general U.S. physician workforce.
Kaiser Permanente PGPs are among the most efficient delivery systems in the
United States. That efficiency, combined with Kaiser Health Plan administrative
simplicity, has generally resulted in premiums some 10 percent or more below
those of competitors. In addition, there is the observation in the recent study
by Chris Ham and colleagues, comparing Kaiser Permanente in California with
the British National Health Service (NHS), that Kaiser Permanente has “shaped
the marketplace” in California by its presence, resulting in lower rates
of hospital use throughout the state.2 This observation
is further supported by recent data from Hewitt Associates showing that 2003
employer health care costs per employee are lower in San Francisco and Los Angeles,
where Kaiser Permanente has dominant market position, than in other major U.S.
metropolitan areas, and some 10 percent lower than the U.S. average.3
Kaiser Permanente PGPs successfully employ a variety of methods known to help
manage costs, promote practice efficiency, and maintain or improve quality at
the same time. Such methods include the use of technology assessment, evidence-based
medicine, team-based care, round-the-clock advice nurse availability by telephone,
active peer review, and compensation systems primarily based on salary. In addition,
as noted by Weiner, Kaiser Permanente PGPs have made extensive use of nurse
practitioners (NPs) and other ancillary providers. In recent years each of our
groups has begun to employ either partially or fully automated medical records
in daily practice. Northwest Permanente and Colorado Permanente have had fully
automated medical records in place for more than five years. In both cases,
the implementation of the fully automated medical record has resulted in a somewhat
reduced demand for medical office appointments.
Although Kaiser Permanente has developed some of the most efficient, highest-quality
practices in the United States, it is difficult to believe that even this accomplishment
can fully explain the 41 percent lower staffing level Weiner finds. It does
not seem to be attributable to fewer patient office visits. Kaiser Permanente
members use an average of 3.6 visits per member per year, compared with an average
of 3.5 visits per member per year for reporting health plan enrollees nationally.4
A sizable portion of the apparent difference in workforce staffing levels between
Kaiser Permanente PGPs and the general U.S. workforce could be explained by
differences in the definition of full-time physician between the two
cohorts studied. Kaiser Permanente’s physician workforce data are based
on physician FTEs, defined as one physician or combination of one or more physicians
working ten units in a given week, or approximately 520 units a year. A unit
is defined as four hours. Thus, an FTE work week is forty hours of scheduled
patient time. Of course, in practice, most Permanente physicians may need to
spend more than forty hours a week, depending on the needs of their patients.
But physician salaries in general and the FTE count are based upon that forty-hour
standard and derive from automated scheduling systems.
On the other hand, the definition of full-time practice used by the American
Medical Association (AMA) and employed as the basis for comparison in both Weiner
papers is based on physicians’ self-reporting to the AMA that they worked
more than twenty hours a week.5 Thus, it is likely
that some of the physicians reported in the AMA database actually work fewer
than forty hours a week in scheduled patient time. If this is the case, then
the full-time definition in the AMA database is not fully comparable to the
forty-hour FTE designation in the Kaiser Permanente database. This would have
the effect of overstating the difference in size between the two workforce staffing
levels. This potential anomaly requires further analysis before firm conclusions
can be drawn.
Changes In The Ratio Of Specialty To Primary Care Physicians
Perhaps the most dramatic finding in Weiner’s current paper is the change
in the ratio of specialty to primary care physicians that occurred between 1983
and 2001 in PGPs, including Kaiser Permanente. In 1983 the ratio of specialty
to primary care physicians in Kaiser Permanente was 51 percent to 49 percent;
in the general U.S. physician workforce it was 65 percent to 35 percent. By
2001 these figures had changed noticeably, but in opposite directions, yielding
an identical ratio of 59 percent specialists to 41 percent primary care physicians
in both the Kaiser Permanente and general U.S. physician workforce populations.
Thus, Kaiser Permanente had seen its specialist workforce grow, while the general
U.S. physician workforce was increasing in its proportion of primary care physicians.
Although it is difficult to speculate on the reason for the increase in the
proportion of primary care physicians in the general U.S. physician population,
I can reflect on changes within the Kaiser Permanente PGPs that led to an increase
in the specialty workforce.
Based on an analysis of the data presented in Weiner’s papers, between
1983 and 2001 the Kaiser Permanente primary care workforce (not including obstetrics
and gynecology) increased by 9 percent. The surgical specialty workforce (including
obstetrics and gynecology) increased by 12 percent. The workforce of medical
subspecialties, including cardiology, gastroenterology, hematology, nephrology,
pulmonology, and others, increased by 37 percent, including an 81 percent increase
in cardiologists. Finally, the number of hospital-based specialists, including
anesthesiology, pathology, and radiology, increased by 44 percent. This suggests
that most of the change took place as the result of sizable additions to the
medical subspecialty and hospital-based specialty physician workforces.
It is interesting to speculate about, but difficult to document, what caused
this change in our PGPs’ workforce. In the Permanente culture, most specialty-staffing
ratios and hiring decisions are made at the local facility level and are primarily
driven by perceived clinical requirements, changes in the science of medicine,
and members’ demand for services. Thus, the observed change is a “bottom-up”
phenomenon and seems to have derived from the inexorable impact of changing
technology on the practice of medicine in our setting.
Examples involving three of the most heavily affected specialties referred to
above (cardiology, radiology, and gastroenterology) serve to illustrate this
point. In each example, the diagnosis or treatment of a common condition in
1983 was well within the purview of the primary care physician but by 2001 had
moved into the purview of the procedure-based specialist. In 1983 cardiac auscultation
by stethoscope, for the diagnosis of both congenital and acquired heart disease,
was a proud part of the armamentarium of primary care physicians, both adult
and pediatric. By 2001 cardiac auscultation, for these purposes, had largely
been replaced by extremely sophisticated echocardiography, a much more sensitive
and specific tool but one performed routinely by highly trained echocardiographers,
a subspecialty barely thought of in 1983.
Similarly, in 1983 breast self-exam and physician breast examination were important
parts of the early detection of breast cancer. By 2001, although both self-
and physician breast examination were still widely practiced, screening mammography
had become the medical “bottom line” for the early detection of breast
cancer. Thus, much of the job of detecting breast cancer has passed from primary
care physicians to highly trained mammographers, a subspecialty of radiology.
In 1983 the most commonly used screening test for the detection of colorectal
cancer was fecal occult blood testing. This test was generally ordered and interpreted
by primary care physicians, in conjunction with routine primary care visits.
While fecal occult blood testing is still used, it has largely been replaced
by screening sigmoidoscopy, and more recently by colonoscopy, both requiring
the talent of highly skilled gastroenterologic endoscopists.
In these cases, and in others, truly effective advances in technology have moved
care increasingly from the primary care environment to the specialty environment.
There is no evidence that this change is abating. It may be the most important
implication for physician workforce policy generated by Weiner’s current
paper.
It is possible that the trend toward increasing specialization seen in Kaiser
Permanente is transitory or cyclical. Fitzhugh Mullan believes that while technological
change does indeed call for “new and as yet unvisioned areas of subspecialization,”
current and future technologies may in fact prove to be countercyclical, by
creating simplified technologies that can become a routine part of primary care
practice.6 Although this may turn out to be the
case, it is not yet evident in the workforce data presented by Weiner, nor in
our experience in the day-to-day planning and delivery of health care services
to a large population.
The Future
As interesting and important as these observations about the past two decades
of physician workforce changes are, it is likely that physician staffing needs
in the next two decades will be shaped by issues other than changes in medical
technology or even physicians’ career preference. The inexorable march
of medical technology has brought with it unsustainable increases in the cost
of health care services. Those cost increases have now set in motion a chain
of events in health care financing, whose results cannot be predicted but will
likely have dramatic effects on the supply of and opportunities for future U.S.
physicians. Attempts to predict future physician workforce needs in the United
States will need to take into consideration the likely impact of technology
change, but such predictions may turn out to be far off the mark, depending
on the outcome of the changes in health care financing that have begun.
Special thanks to Robert Crane, Walter Meyer, Jon Stewart, Sharon Levine,
and Joseph Selby for their thoughtful reviews of this paper.
NOTES
1. J. Weiner, “Forecasting the Effects of Health Reform
on U.S. Physician Workforce Requirement: Evidence from HMO Staffing Patterns,”
Journal of the American Medical Association 272, no. 3 (1994): 222–230.
2. C. Ham et al., “Hospital Bed Utilization in the English
National Health Service, Kaiser Permanente, and the United States Medicare Programme:
Analysis of Routine Data,” British Medical Journal 327, no. 7426
(2003): 1257–1262.
3. Hewitt Associates, “Hewitt Health Value Initiative,
2003” (Lincolnshire, Ill.: Hewitt Associates LLC, 2003).
4. This comparison is for 2002 and is derived from Kaiser Permanente
data and the “Quality Compass 2003” of the National Committee for
Quality Assurance in Washington, D.C.
5. American Medical Association, Physician Characteristics
and Distribution in the U.S., 2002–2003 ed. (Chicago: AMA, 2002); and
Penny Havlicek, Survey and Planning Department, American Medical Association,
personal communication, 5 December 2003.
6. F. Mullan, “Time-Capsule Thinking: The Health Care Workforce,
Past and Future,” Health Affairs (Sep/Oct 2002): 112–122.
(Jan/Feb 2002): 160–162.
Jay Crosson (jay.crosson{at}pk.org)
is executive director of the Permanente Federation, Kaiser Permanente Health
Care Program, in Oakland, California.
Please click on the author's
names to read related papers by Jonathan
Weiner, W.
Bruce Fye, David
C. Goodman,
Fitzhugh Mullan, Edward
Salsberg and Gaetano Forte, and Stephen
C. Schoenbaum.
DOI: 10.1377/hlthaff.W4.60
©2004 Project HOPE–The People-to-People Health Foundation, Inc.
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