Pediatric Workforce Statement

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AMERICAN

ACADEMY

OF

PEDIATRICS

Pediatric

Workforce

Statement

Committee on Careers and Opportunities

Developing accurate forecasts for physician

work-force needs is an extraordinarily difficult task. In

1980

the Graduate Medical Education National

Ad-visory Commiftee (GMENAC) completed a

compre-hensive workforce study. Based on estimates of

growth of the number of pediatricians, GMENAC

predicted a potential excess of 4950 pediatricians by

1990.1 The American Academy of Pediatrics (AAP)

studied the report and issued a response in 1981 that

questioned many elements in the model.2 However,

the Academy was concerned that an excess number

of pediatricians would be produced by the 1990s, and

a statement published in 1985 and revised in 1987

recommended government and academic policies

ensuring the production of pediatricians of the high-est quality, but in fewer numbers.3

Subsequent to the 1987 statement, consistent

cvi-dence has pointed to shortages of pediatricians

rather than the projected surplus in all regions of the country. A 1990 survey of residency program direc-tors provided the strongest empirical evidence to date that the supply of new pediatricians is not meet-mg the demand.4

In 1990, the Council on Graduate Medical

Educa-lion (COGME) contracted with the consulting firm of

Abt Associates, Inc to reexamine the adequacy of

physician workforce supply. The resulting report,

commonly referred to as the Abt report, contends

there would be an even greater oversupply of

pedia-tricians than projected in the 1980 GMENAC report.5

The AAP concerns with this report’s methodology

and conclusions were strongly voiced to the COGME and in the literature.6’7 Subsequent to the Abt Report,

the COGME published a report which emphasizes a

growing shortage of practicing generalists (ie, gen-eral pediatricians, general internists, and family phy-sicians) and calls for an increase in the percentage of residents who complete a 3-year training program in the generalist specialties.8

Given the conificting assessments of the pediatric

workforce situation, and persistent misconceptions

about an oversupply of pediatricians, it is

appropri-ate that the Academy issue a current statement on

pod iatric workforce.

PEDIATRIC WORKFORCE

Trends in Pediatric Workforce Supply

According to the most recent data collected by the

American Medical Association (AMA), in 1992 there

Acad-erny of Pediatrics.

were 44 881 self-designated pediatricians (both

board-certified and non-board-certified) in the

United States. The main professional activity of more than 90% of these pediatricians was the provision of patient care in office and hospital-based settings. The remainder were engaged in other professional activi-ties, such as administration, medical teaching, or re-search.9

In 1992, 28% of all pediatricians were younger than 35 years of age, and another 35% were between the ages of 35 and 44 years, which makes pediatricians, on average, younger than other physicians.9

A noteworthy trend in the pediatric workforce is

the growing number of women entering the spe-cialty. Since 1970, pediatrics has been on the leading

edge of the increase in numbers of women in

mcdi-cine. In 1992, 40% of all pediatricians were women, compared with approximately 21 % of all physicians in internal medicine and 18% of all physicians.9

The number of international medical graduates

(IMGs) in pediatrics has tripled since 1970. IMGs now comprise 29% of the pediatrician population,

compared with 22% of the total physician

popula-tion.9 The immigration status of IMGs, along with

fluctuations in the US birthrate, variations in practice patterns, and health care reform (discussed in follow-ing sections), are four factors that are likely to have the most impact on future pediatric workforce pro-jections.

Pediatricians in Training

Approximately 6200 pediatricians are in residency

at any one time.10 Additionally, more than 1000

fel-lows are in subspecialty training.11 Currently there are 215 accredited US pediatric training programs. Of pediatric residents 56% are women, and 32% of pe-diatric residents are IMGs.10’12

During the past several years, interest in primary

care specialties has declined among US medical

stu-dents. However, unlike the other primary care spe-cialties, pediatrics has not experienced a dramatic

decline in the percentage of US medical students

choosing pediatric residency programs.13 This is due in part to the large number of women selecting pe-diatric residencies.

For the past 8 years, approximately 10% of US medical school graduates matched in the National Resident Matching Program (NRMP) have chosen pediatrics.13 In 1993, 105% of matching US medical

school graduates (1361) matched 66.5% of the

pedi-atric PGY-1 slots (2046) offered through the NRMP.13

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positions were filled by graduates of Canadian schools, doctors of osteopathy, and 5th Pathway

stu-dents.13 A significant number of the remaining

pedi-atric positions are filled outside of the match by IMGs. This has workforce implications for pediatrics, because the immigration status of IMGs is difficult to predict.

Residency programs are federally supported by direct medical education grants based on the number

of residents and per resident costs, and indirect

medical education support which adjusts Medicare

payments in recognition of higher costs of patient care in teaching institutions. Additional primary care

grants are provided through the Title VII program.

The future funding of graduate medical education

(GME) will have serious implications for pediatrics.

In its first report in 1988, the COGME concluded that

GME funding was eroding, and that substitute

sources were not developing to take the place of patient care reimbursements.14 Consequently, the

American Academy of Pediatrics believes that

fed-eral grant support (including the Title VII program) is vital to all primary care GME, including pediat-rics.15 Furthermore, the Academy believes it is criti-cal to insist on the inclusion of pediatrics and pedi-atric training programs in all primary care incentive programs.

With the significant increase in the number of

women in pediatrics, and with the increase of

dual-career marriages, life-style and child-rearing consid-erations greatly influence employment decisions of

both women and men. Data from the American

Medical Association’s 1988 annual survey indicate

that, on average, women in pediatrics devoted about

87% as many hours per week to medical practice and saw about 78% as many patients per year as did their male counterparts.16 In light of the fact that a major-ity of current pediatric residents are women, we fully

anticipate a decline in the mean number of patients

seen per year by pediatricians. Any attempt to project future numbers of pediatricians must adjust for this factor.

Another point to consider when examining the pe-diatric workforce is the fact that 32% of pediatric

residency positions are currently filled by IMGs.12

More than one fourth of IMGs are “exchange

visi-tors” and must return to their countries after training is completed, decreasing the number of pediatricians entering practice after training in the United States.1#{176}

The Academy has determined that the following

factors are key issues that must be considered when

developing pediatric workforce policy: utilization,

provision of care by other providers, pediatric

sub-specialization, ethnic composition, indebtedness,

geographic distribution, and reimbursement.

KEY FACTORS INFLUENCING PEDIATRIC

WORKFORCE

Utilization

Contrary to earlier predictions, research reveals a

growing, rather than a diminishing market for

pe-diatricians. In a study published in Pediatrics,

resi-dency directors report a 96% placement rate in 1990,

a year widely predicted to be one of “pediatrician

glut.”4 Furthermore, there are indications of an even greater demand for pediatricians in the future. For

example, the US Census Bureau predicted that there

would be 3.7 million live births in 1990, when the

actual number of live births was 4.2 million.5’17 The

Bureau also predicted that by the year 2000 there

would be 66 million children younger than 18

years.18 Fluctuations in the pediatric population have

a great impact on workforce needs and must be

fac-tored into workforce models.

Trends indicate that utilization of pediatricians has increased and will continue to increase in the future.

For example, data from the National Ambulatory

Medical Care Survey (NAMCS) reveal that of the 13 largest specialties, pediatrics was the only specialty showing a significant increase in percentage of all

office visits between 1985 and 1989, from 11.4% to

12.6%.19 Jg the 12-month period from March 1989 to March 1990, visits to pediatricians accounted

for 87.4 million of the 692.7 million ambulatory care

office visits made to physicians in the United

States.19 One possible explanation for increased visits to pediatricians is the increase in the number of

chil-dren enrolled in Medicaid and managed health care

plans, both of which generally cover ambulatory care

services more than traditional indemnity plans. Another explanation for increased visits is the fact that pediatricians are increasingly providing health

services to all children, especially adolescents from

14 to 21 years of age.2#{176}According to AAP policy, the scope of pediatrics includes infants, children, adoles-cents, and young adults. In many settings (eg, college health centers, centers for treatment of chronic ill-ness), pediatricians actively participate in the care of young adults beyond the age of 21 years. Success-fully addressing the needs of adolescents will con-tinue to affect pediatric workforce needs, as only 24%

of adolescent care is now delivered by

pediatri-cians.2#{176}

The Academy believes that the need for

pediatri-cians will increase, due in part to the growth of new

morbidities such as acquired immunodeficiency

syn-drome, behavioral and learning problems, divorce,

family violence, and child abuse; the medical needs

of an increasing population of homeless children,

currently estimated to number a half a million plus; and the abuse of tobacco, alcohol, and other sub-stances. Furthermore, the increasing public and

gov-ernmental concerns about the large numbers of

un-insured and underinsured Americans may soon lead

to passage of a national health policy, addressing the

presently unmet health care needs of children. En-actment of such legislation would help eliminate the financial barriers to needed health care for a great number of children, generating an increase in pedi-atric contacts ranging from an estimated 5% (Lewin/

ICF study commissioned by the American Academy

of Pediatrics) to 15%.21 The Academy believes that

the development of accurate physician workforce models must take these issues into account.

Other Health Care Providers

Allied Health Professionals. Past workforce models

have assumed that pediatric nurse practitioners

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

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(PNPs) could deliver from 15%1 to 33%5 of health care services to children. However, for a number of reasons, the rate at which care is delegated is

be-lieved to be much lower than that. There are an

es-timated 6000 active PNPs in the United States, and this total has been relatively constant for the past 10 years.6 Furthermore, although PNPs are frequently suggested as lower cost replacements for

pediatri-cians, they are often a comparable rather than a

lower cost option due to increasing PNP salaries, limited working hours, fewer patients seen per hour as compared with physicians, and the need for

su-pervision by physicians. The PNPs function well

with assigned protocols but are not trained in

differ-ential diagnosis and treatment of a broad spectrum of

pediatric problems. Therefore, the Academy believes

that PNPs function most effectively in teams directed by pediatricians.

Family Practitioners. In the past, physician

work-force studies have estimated that about 15% to

25%22 of services to children are delivered by family

practitioners and in rural areas this percent may be

higher. However, pediatricians continue to treat the

largest percentage of children in the infant and pre-school age groups.19 Moreover, in the past a

signifi-cant number of older children and adolescents have

received care from family practitioners, but

pediatri-cians are increasingly being consulted and

recog-nized as the primary health care experts for these age groups as well.2#{176}

Pediatric Subspecialization

In recent years, both the number of pediatric sub-specialties and the number of pediatricians in sub-specialties have grown. Currently, there are twelve certificate subspecialties, and the certification of

ad-ditional subspecialties is expected. Some pediatric

subspecialty training-such as general ambulatory,

adolescent, and developmental pediatrics-is often

undertaken to enhance the pediatrician’s ability to

provide optimal primary care services. Many

pedia-tricians take 1 or 2 years of subspecialty training and

then enter primary care practice. Others specialize in

highly technical areas and care for children with

complex diseases. Fortunately, the life-span of many

of these children is lengthening, thereby increasing

the need for subspecialty care. The Academy believes

that all children with complex diseases should have

a primary care pediatrician, as well as available and

appropriate consultations with pediatric subspecial-ists.

Pediatrics has shared in the increase in technology available for diagnosis and management of patients, much of which requires subspecialty training. Cur-rently, more than 50% of all pediatric subspecialists are pediatric allergists or neonatologists. Many full-time pediatric subspecialists such as cardiologists, neonatologists, hematology/oncologists, endocri-nologists, and nephrologists are almost exclusively employed in medical schools or teaching hospitals and have limited private practices. Despite this fact, many teaching institutions are experiencing an

un-dersupply of pediatric faculty in the basic and

cmi-cal sciences.1#{176}

Although some have predicted an oversupply of

neonatologists and pediatric allergists, the Academy cannot accurately predict the need for pediatric sub-specialists. This is because the increased demand for subspecialists due to the new morbidities faced by children today points to a continuing need for pedia-tricians in both primary care and subspecialty prac-tice.

Ethnic Composition

Except for Asian physicians, minorities are mark-edly underrepresented in all specialties including pediatrics. According to the AAP Department of Research, 2.7% of all pediatricians are black,

non-Hispanic; 0.1% are American Indian or Alaskan

Na-five; 15.7% are Asian or Pacific Islander; and 5.3% are

Hispanic, compared with 75.9% who are white,

non-Hispanic. (These figures are approximations based on the 1991 AMA Physician Masterifie and do not include residents.) The number of black pediatric residents increased between 1978 and 1990 (from 274

to 363),24 but the growth remains slow and the total

numbers low.

The widening disparity in the health status

be-tween nonminority children and minority children has received considerable attention during the past few years. In fact, many of the US Public Health Service’s “Healthy People 2000 Objectives” are in-tended to address the high concentration of disease and disability among racial and ethnic minority

populations.25 Minority children are found to have

less access to health care, independent of their health status, sex, economic status, health insurance status, and place of residence.26

Increasing the number of minority health care pro-viders has the potential to increase minority popula-tions’ access, thereby offsetting some of the

difficul-ties that minorities have experienced in obtaining

adequate health care.27 Minority physicians are more

likely to be more sensitive to the culture of their minority patients and to practice in underserved ar-eas, thereby having the potential to deliver health

care services more effectively? Furthermore,

mi-nority pediatricians have a unique opportunity to

serve as role models, influencing children and ado-lescents to choose careers in medicine. The Academy

therefore supports the implementation of methods

ensuring that more minority medical students choose primary care pediatrics. Furthermore, the Academy believes that barriers such as medical student

indebt-edness, which is significantly higher for minority

medical students,#{176} must receive immediate

atten-tion. The American Academy of Pediatrics believes

that more minority pediatricians will not in itself

solve the problem of lack of access to care for minor-ity children; however, more caring, concerned phy-sicians who are involved in primary care and

pro-viding health care for minority infants and children

can affect the health status of minorities.31

Indebtedness

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have indicated that indebtedness is an important is-sue as perceived by medical students in specialty selection.31’35 According to a recent survey of resi-dents conducted by the Association of American Medical Colleges (AAMC) (1987 through 1990), 80% of the respondents were in debt, and the average

debt was $41 000.31 In fact, in 1990 the AAMC

re-ported that an accumulated debt of $75 000 is typical for 11 % of medical school graduates.31

The Academy is concerned that indebtedness is quite likely to be a contributing factor influencing medical students and residents to choose higher pay-ing specialties and subspecialties at the expense of all primary care specialties, including pediatrics. Fur-thermore, the Academy is also concerned with the disproportionate impact that indebtedness may have on efforts to increase the number of minorities in medicine. Addressing the complex issue of medical student indebtedness through loan repayment! forgiveness programs is one avenue that the Acad-emy believes must be pursued if pediatrics is going to be able to maintain and enhance its ability to at-tract medical students of the highest caliber into the specialty.

Geographic Distribution of Pediatricians

The variability in the geographic distribution of general pediatricians needs to be factored into any analysis of pediatric workforce. Although the total number of pediatricians has been steadily increasing, a shortage of pediatricians remains in rural areas and impoverished urban areas. There are several bamers that must be overcome to encourage the location of pediatric practices in underserved areas. The most obvious is financial viability with respect to the often limited child population in rural areas, and the large uninsured or Medicaid-insured populations in both rural and urban underserved areas. Other disincen-tives include life-style considerations, including so-cial, cultural, and educational opportunities, and the availabifity of medical resources, eg, location of hos-pital facilities, access to continuing medical educa-tion, coverage respite, proximity of medical col-leagues, career opportunities for spouses.

The Academy supports financial incentives at both the state and national levels to attract and retain pediatricians in underserved areas. This should be a multifaceted approach that considers issues such as expansion of the National Health Service Corps, other loan forgiveness programs, financial incentives and reimbursement differentials in Medicaid, and other publicly financed care.

Reimbursement

Pediatricians have historically earned incomes

ap-proximately 25% less than the average income of all physicians.36”7 However, data from the last several years indicate that this income gap is being reduced, a trend not experienced by other primary care spe-cialties.38

Lower incomes among pediatricians are mainly a result of the inadequate health insurance status of their patients. According to the Employee Benefit Research Institute, 11.8 million children younger

than 21 years of age were uninsured in 1991. Fur-thermore, a great proportion of children are under-insured because many insurance companies do not provide coverage for preventive care or services needed by chronically ifi children.

A major source of insurance for children is the Medicaid program. In 1991, nearly 14 million chil-dren received Medicaid benefits.’#{176} Children repre-sent more than half of all Medicaid beneficiaries in this country. Although Medicaid is relatively gener-ous in terms of eligibility for children (as compared with poor and low-income citizens in other age groups), benefits are constrained and vary greatly by state, and reimbursement is extremely low. In 1989 pediatricians received on average 57% of their usual fee for established patient visits and 70% of their usual fee for new patient visits from Medicaid.41 The program paid approximately 80% of Medicare rates and provided a reimbursement level slightly higher than the average overhead cost required to provide care.’#{176}”

Some of the economic inequalities among physi-cians are being addressed through the resource-based relative value scale (RBRVS) payment system. Because pediatrics is not a Medicare-utilized spe-cialty, the RBRVS has had a minimal effect on

pedia-trician income. However, with the recent

prolifera-tion of the use of RBRVS-determined reimbursement

by state Medicaid programs and private insurers,

this situation is changing. The development of a com-prehensive, pediatric-specific RBRVS would help to alleviate the disparity in income between pediatrics and other specialties, which in turn could affect the shortage and geographic maldistribution of pediatri-cians in the United States.

CONCLUSIONS

The absolute number of physicians caring for

cM!-dren is increasing, yet significant unmet health needs in the pediatric population exist. The majority of child health objectives established by the Surgeon General for the year 1990 were not achieved. With nearly 12 million children uninsured, and millions more underinsured, children’s access to care is mad-equate.

An increase in the number of pediatricians is nec-essary to meet the health needs of US children. This must be coupled with improved geographic distri-bution and an increase in representation of certain minority groups in pediatrics. Thus, the Academy supports the following recommendations for action. Support the continued education and training of pe-diatricians.

. Encourage medical school admissions committees to select students with an interest in primary care. . Support recruitment efforts to encourage medical

students of the highest caliber to select pediatrics as a career.

. Advocate for adequate and realistic reimburse-ment for pediatric services to aid recruitment ef-forts.

. Support efforts to increase the enrollment of mi-nority students in medical school.

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. Encourage specific recruitment of underrepre-sented minority students into pediatrics.

. Insist on the inclusion of pediatrics and pediatric

training programs in all primary care incentive

programs at the local, state, and federal level. En-sure that policymakers recognize pediatrics as a primary care specialty.

. Support the restructuring of student loan

repay-ment schedules so they are based on a percentage

of earnings rather than fixed payments regardless

of specialty choice.

. Support adequate and realistic reimbursement for

pediatric services to help alleviate the disparity in income that exists between pediatrics and other specialty fields.

. Support changes in GME financing which favor the training of primary care physicians.

Seek the remediation of the undersupply of pediatri-cians in rural and inner-city areas.

S Support creative student loan forgiveness

pro-grams for physicians practicing in targeted, under-served areas.

. Support the expansion of the National Health Ser-vice Corps.

. Explore reimbursement differentials in Medicaid

and other publicly financed care to pay higher

rates for services delivered in identified under-served areas.

. Explore the creative use of tax credits and other

means as financial incentives to physicians for pro-viding care in identified underserved areas. Support national workforce planning efforts.

. Continue to provide accurate, timely information

to the COGME Physician Manpower

Subcommit-tee, congressional subcommittees, and other

gov-ernmental entities.

. Support the development of realistic, scientifically sound workforce models for both primary and subspecialty pediatric care.

. Continue monitoring of the pediatric workforce

issue by following the significant changes occur-ring in the delivery and funding of health care.

Commii ON CAREERS 1tit OppoRTuNmEs, 1992 to 1993 Robert L. Johnson, MD, Chair

Marion J. Balsam, MD

M. Rosario Gonzalez-De-Rivas, MD Mary Antenen Mdllroy, MD Wanessa P. Risko, MD Jeffrey J. Stoddard, MD Doris Wethers, MD

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Pediatrics