The Government’s Concerns Regarding Postgraduate Training and Health Care Delivery
THEODORE COOPER, MD, FACC” Washington,
D. C.
I am pleased that you have included in your Symposium on the training of cardiologists a consideration of the federal role in the burgeoning business of health care. Some of us are concerned that one of the major issues is the burgeoning federal role in the business of health care. In many ways, and for a long time, medicine-or the biomedical world-has escaped the usual consequences of external (in this case “public”) financing. It is estimated that total national health care expenditures may reach $125 billion of those dollars. Thus the public has bought a large share of the so-called health industry and (as any major stockholder is wont to do) is demanding a greater voice in policy formulation and program development. It is essential, therefore, that you-as you devise directions, based appropriately on your professional judgment-talk with (not only listen to) the public. If you can retain that special confidence that people still have in the medical profession, and if you can find ways to limit direct federal financing and if you propose solutions and do not limit yourselves to reaction to proposals, you can maintain your leadership role. I get the impression that the public is looking for competent physicians and allied health professionals to be accessible and in good supply. Further, there is the expectation-perhaps the result of televised medicine and glamorous stories about doctors and hospitals-that health facilities and equipment will be modern, up-to-date and conveniently located. All members of our society prefer, and indeed expect to receive, the products and results of the best available scientific research and technology. They equate these characteristics with quality care. People have bought the notion that health is a right. A derivative of this idea is that care should not be limited by a financial barrier. ‘ Assistant Secretary for Health, U. S. Department of Health, Education, and Welfare, Washington, D. C. Address for reprints: Theodore Cooper, MD, Assistant Secretary for Health, Room 5077, HEW North Building, 330 Independence Ave., SW, Washington, D. C. 20201.
To reach these expectations, many laws have been or will be devised. I will only highlight a few-among amendments to the Social Security Act are those dealing with professional standards review, and end stage renal disease; Title I of the National Research Act will have impact on how, in the future, research training will contribute to the making of a cardiologist; Title II of the National R.esearch Act will result in standards of ethics in human investigation that will affect your practice. There will probably be new laws governing malpractice situations. There is landmark legislation in the National Health Planning and Resource Development Act of 1974-and there may be new manpower legislation this year. Therefore, responsible leadership in the training of cardiologists of tomorrow requires not only an appreciation of the public expectation, but also a comprehensive assessment of the legal framework within which you will have to operate.
Current Directions of Medical Training There are four issues relating to postgraduate training that should merit your special attention, for they will be the focus of much of the debate that will envelop considerations of manpower law: 1. The composition of the physician pool. 2. Geographic maldistribution of physicians. 3. The service of minority groups. 4. The utilization of foreign medical graduates. Composition of physician pool: There is still some controversy as to whether there is an absolute shortage in the total number of physicians. There is also some debate as to whether there are potential shortages in selected specialties. Current sources of data and our best estimates seem to indicate that general and family practitioners and physicians in several other specialty areas are clearly underrepresented at present and will continue to be for some time. Pediatrics is projected to have a balance between supply and demand for the rest of this decade. General surgery and orthopedic surgery appear to be overrepresented at present and are predicted to be in oversupply during the next half decade. Studies
October 31.1975
The American Journal of CARDIOLOGY
Volume 36
555
GOVERNMENT AND POSTGRADUATE TRAINING-COOPER
in cardiology suggest you are in modestly short supply -but some of your brethren say there are enough. One hundred years ago, there were seven physician specialties. Today, there are more than 64 specialty areas recognized by the American Medical Association. This trend toward ultraspecialization has led some members of the federal health establishment to want to reevaluate the current direction of medical training as it relates to the perceived need for more primary care physicians. This interest, by the way, is not uniquely limited to the federal health establishment. It is becoming generally accepted by members of the private sector, such as the Coordinating Council on Medical Education, the AMA’s House of Delegates and others, who adopted a resolution 2 years ago to set a goal to have at least 50 percent of U.S. medical graduates go into primary care residencies. This figure of 50 percent has been repeated so often that it is now the primary figure for all planning. We think that new laws should contain specific language to encourage the graduation of substantially more primary care physicians. All of this interest in primary care physicians is fueled by specialty and manpower figures that show a measurable decline between 1963 and 1972 in the percentage of physicians going into primary care. This decline amounted to a reduction in primary care physicians from 48 to 44.6 percent of the total number of physicians compared with a 2 percent increase in surgeons and other specialists. I acknowledge that much of this perceived require-; ment for primary care physicians is based more on informal judgment than on carefully compiled statistical data. Nevertheless, the attitude that there is a legitimate need for these kinds of physicians is gaining support among members of Congress, the public and the medical profession. Much of the past work on manpower has unfortunately been descriptive in nature and has relied heavily on physician population experiences of other ratios, informed judgment, countries, limited data from various health care delivery systems such as HMO’s, and other proxies. As a result, the establishment of commonly accepted health service delivery goals that would assist in defining criteria for the allocation of resources, including manpower, is very difficult. We have found your efforts and the activities of physicians in other specialties, such as radiology, dermatology, orthopedic surgery and, recently, some of the other surgical specialties, to be very helpful in attempting to assess individual supply and needs. However, we cannot rely solely on your limited appraisals of individual segments of the total manpower picture. Further, we cannot continue to rely upon AMA data, which are sometimes unavailable. This is not a criticism because there are no other at present. They are often inadequate for purposes of policy analysis and for the needs of national health insurance coming down the pike. With the current health planning bill in our laps, and a predominant interest in areas of shortage in primary medical care, the fed-
556
October
31, 1975
The American
Journal ot CARDIOLOGY
eral government must either have greater access to physician data or develop a cooperative or independent system to acquire accurate and detailed confidential data on members of the health profession, or both. Geographic maldistribution of physicians: In contradistinction to the question of total manpower supply, there is no dispute that there is geographic maldistribution of physicians in this country. In the 1960’s and early 1970’s, we experienced a significant increase in the physician to population ratio, yet disparities in the distribution of physicians continue to exist. Population groups in rural areas and in the inner city still have difficulty gaining access to health care. In the past, federal policies toward specialty and geographic distribution of health professionals have relied too heavily on the notion that an increase in total supply would solve the distribution problems. It was reasoned that if enough health professionals were produced, competitive pressure would force them to practice in nonmetropolitan areas and in the less attractive medical specialties. Experience has shown this reasoning to be incorrect. We know now, for example, that important factors determining the geographic location of physicians turn out to be such considerations as: the cultural amenities of the community, the educational system for children in the community, social and environmental factors including personal safety, the economic base of the community and the interest and preference of the spouse. Furthermore, experience in other countries has suggested that policies aimed at solving the problem of geographic and specialty maldistribution that concentrate on increasing the aggregate supply of health manpower are expensive and largely ineffective. Unified health planning, as proposed in the new National Health Planning and Resource Development Act of 1974, could provide the means by which health service requirements can be determined at the local level and translated into corresponding national health manpower requirements. Implicit in the unified approach is the fact that no single element can be analyzed alone. Consideration of specialty distribution, for example, cannot be isolated from issues of geographic distribution of manpower and access to the health services. It must be examined in the context of physician productivity and task delegation, the composition and mix of local health teams, the utilization of nonphysician health workers and the quality and overall cost of health care. Service of minority groups: A word about socioeconomically disadvantaged students. This issue also interlocks with the problems of specialty and geographic maldistribution. Limited data on ethnic minority and other disadvantaged students show that they are concentrated in a relatively few specialty areas. One-quarter of active black physicians, for example, are engaged in general practice in their primary communities and provide service to an otherwise unserved area. I believe that this trend should
Volume
36
GOVERNMENT AND POSTGRADUATE TRAIN~CDDPER
be supported and encouraged while we increase their ranks with qualified students and well trained physicians.
such gaps as collecting data and developing adequate methodologies for estimating supply.
Utilization of foreign medical school graduates: A sensitive and important facet of our health
Federal Role in Manpower and Postgraduate Training
manpower problem is the complex issue of graduates of foreign medical schools. The debate centers on two primary issues, namely, the quality and the number of such graduates entering the U.S. for training and the practice of medicine. While it appears that the increasing numbers of graduates of foreign medical schools entering and being licensed in the U.S. has served to incite much of the public debate, there is, in fact, an overriding issue of quality. We will support the creation of a truly national qualifying examination to develop and implement a single standard of quality for all medical graduates, foreign as well as U.S., who enter and remain in the U.S. health care system. We shall also evaluate what the revision of immigration law might accomplish toward the stabilization of a federal health manpower policy.
I have no difficulty accepting a federal role to provide technical assistance and to monitor performance. I have considerable reservation about a primary federal role in directing postgraduate training. I suspect that some of you believe that voting federal or public money for postgraduate programs does not mean that you want us to decide what they are to be and how they are to be implemented. I submit that that is naive. It is fashionable today to require “impact” statements-environmental; economic-for new or renewed programs. In proposing your solutions, consider their impact on your independence and on your individuality. Are independence and individuality an important part of quality medicine or health care? If not, we can find a way to distribute you by the numbers. Now for health manpower. House and Senate conferees of the Congress were unable to agree in late December 1974 on new health manpower legislation to replace the Comprehensive Health Manpower Act of 1971, which expired on June 30, 1974. This task was postponed for future years. I cannot predict which manpower bill will be passed by Congress. What I can predict is that it will contain elements addressed to the problems of geographic distribution, specialty and total physician shortages, capitation, the effective delivery of primary care, and the tough question of graduates of foreign medical schools. A new area of concern in the area of manpower will be the potential problems of inadequate supply, overutilization and worsening manpower distribution brought on by the advent of national health insurance.
Role of the Private Sector Many other specific and technical items will need to be considered before final decisions are made on the new federal program-the fate of capitation, the use of student scholarships, the concept of the National Health Service Corps, to mention a few. I would prefer that the private sector take the lead in solving these issues. I believe that specialty organizations like yours can play a major role in accurately determining specialty supply and manpower needs. However, these can only be effectively done in the context of the total manpower picture. Whenever members of the private sector are unable to, or fail to, address important aspects of the problem, you can be sure that someone will suggest that the federal government should do it. We shall try to help fill in
October 31, 1975
The American Journal ot CARDIOLOGY
Volume 36
557
THEODORE COOPER, MD, FACC” Washington,
D. C.
I am pleased that you have included in your Symposium on the training of cardiologists a consideration of the federal role in the burgeoning business of health care. Some of us are concerned that one of the major issues is the burgeoning federal role in the business of health care. In many ways, and for a long time, medicine-or the biomedical world-has escaped the usual consequences of external (in this case “public”) financing. It is estimated that total national health care expenditures may reach $125 billion of those dollars. Thus the public has bought a large share of the so-called health industry and (as any major stockholder is wont to do) is demanding a greater voice in policy formulation and program development. It is essential, therefore, that you-as you devise directions, based appropriately on your professional judgment-talk with (not only listen to) the public. If you can retain that special confidence that people still have in the medical profession, and if you can find ways to limit direct federal financing and if you propose solutions and do not limit yourselves to reaction to proposals, you can maintain your leadership role. I get the impression that the public is looking for competent physicians and allied health professionals to be accessible and in good supply. Further, there is the expectation-perhaps the result of televised medicine and glamorous stories about doctors and hospitals-that health facilities and equipment will be modern, up-to-date and conveniently located. All members of our society prefer, and indeed expect to receive, the products and results of the best available scientific research and technology. They equate these characteristics with quality care. People have bought the notion that health is a right. A derivative of this idea is that care should not be limited by a financial barrier. ‘ Assistant Secretary for Health, U. S. Department of Health, Education, and Welfare, Washington, D. C. Address for reprints: Theodore Cooper, MD, Assistant Secretary for Health, Room 5077, HEW North Building, 330 Independence Ave., SW, Washington, D. C. 20201.
To reach these expectations, many laws have been or will be devised. I will only highlight a few-among amendments to the Social Security Act are those dealing with professional standards review, and end stage renal disease; Title I of the National Research Act will have impact on how, in the future, research training will contribute to the making of a cardiologist; Title II of the National R.esearch Act will result in standards of ethics in human investigation that will affect your practice. There will probably be new laws governing malpractice situations. There is landmark legislation in the National Health Planning and Resource Development Act of 1974-and there may be new manpower legislation this year. Therefore, responsible leadership in the training of cardiologists of tomorrow requires not only an appreciation of the public expectation, but also a comprehensive assessment of the legal framework within which you will have to operate.
Current Directions of Medical Training There are four issues relating to postgraduate training that should merit your special attention, for they will be the focus of much of the debate that will envelop considerations of manpower law: 1. The composition of the physician pool. 2. Geographic maldistribution of physicians. 3. The service of minority groups. 4. The utilization of foreign medical graduates. Composition of physician pool: There is still some controversy as to whether there is an absolute shortage in the total number of physicians. There is also some debate as to whether there are potential shortages in selected specialties. Current sources of data and our best estimates seem to indicate that general and family practitioners and physicians in several other specialty areas are clearly underrepresented at present and will continue to be for some time. Pediatrics is projected to have a balance between supply and demand for the rest of this decade. General surgery and orthopedic surgery appear to be overrepresented at present and are predicted to be in oversupply during the next half decade. Studies
October 31.1975
The American Journal of CARDIOLOGY
Volume 36
555
GOVERNMENT AND POSTGRADUATE TRAINING-COOPER
in cardiology suggest you are in modestly short supply -but some of your brethren say there are enough. One hundred years ago, there were seven physician specialties. Today, there are more than 64 specialty areas recognized by the American Medical Association. This trend toward ultraspecialization has led some members of the federal health establishment to want to reevaluate the current direction of medical training as it relates to the perceived need for more primary care physicians. This interest, by the way, is not uniquely limited to the federal health establishment. It is becoming generally accepted by members of the private sector, such as the Coordinating Council on Medical Education, the AMA’s House of Delegates and others, who adopted a resolution 2 years ago to set a goal to have at least 50 percent of U.S. medical graduates go into primary care residencies. This figure of 50 percent has been repeated so often that it is now the primary figure for all planning. We think that new laws should contain specific language to encourage the graduation of substantially more primary care physicians. All of this interest in primary care physicians is fueled by specialty and manpower figures that show a measurable decline between 1963 and 1972 in the percentage of physicians going into primary care. This decline amounted to a reduction in primary care physicians from 48 to 44.6 percent of the total number of physicians compared with a 2 percent increase in surgeons and other specialists. I acknowledge that much of this perceived require-; ment for primary care physicians is based more on informal judgment than on carefully compiled statistical data. Nevertheless, the attitude that there is a legitimate need for these kinds of physicians is gaining support among members of Congress, the public and the medical profession. Much of the past work on manpower has unfortunately been descriptive in nature and has relied heavily on physician population experiences of other ratios, informed judgment, countries, limited data from various health care delivery systems such as HMO’s, and other proxies. As a result, the establishment of commonly accepted health service delivery goals that would assist in defining criteria for the allocation of resources, including manpower, is very difficult. We have found your efforts and the activities of physicians in other specialties, such as radiology, dermatology, orthopedic surgery and, recently, some of the other surgical specialties, to be very helpful in attempting to assess individual supply and needs. However, we cannot rely solely on your limited appraisals of individual segments of the total manpower picture. Further, we cannot continue to rely upon AMA data, which are sometimes unavailable. This is not a criticism because there are no other at present. They are often inadequate for purposes of policy analysis and for the needs of national health insurance coming down the pike. With the current health planning bill in our laps, and a predominant interest in areas of shortage in primary medical care, the fed-
556
October
31, 1975
The American
Journal ot CARDIOLOGY
eral government must either have greater access to physician data or develop a cooperative or independent system to acquire accurate and detailed confidential data on members of the health profession, or both. Geographic maldistribution of physicians: In contradistinction to the question of total manpower supply, there is no dispute that there is geographic maldistribution of physicians in this country. In the 1960’s and early 1970’s, we experienced a significant increase in the physician to population ratio, yet disparities in the distribution of physicians continue to exist. Population groups in rural areas and in the inner city still have difficulty gaining access to health care. In the past, federal policies toward specialty and geographic distribution of health professionals have relied too heavily on the notion that an increase in total supply would solve the distribution problems. It was reasoned that if enough health professionals were produced, competitive pressure would force them to practice in nonmetropolitan areas and in the less attractive medical specialties. Experience has shown this reasoning to be incorrect. We know now, for example, that important factors determining the geographic location of physicians turn out to be such considerations as: the cultural amenities of the community, the educational system for children in the community, social and environmental factors including personal safety, the economic base of the community and the interest and preference of the spouse. Furthermore, experience in other countries has suggested that policies aimed at solving the problem of geographic and specialty maldistribution that concentrate on increasing the aggregate supply of health manpower are expensive and largely ineffective. Unified health planning, as proposed in the new National Health Planning and Resource Development Act of 1974, could provide the means by which health service requirements can be determined at the local level and translated into corresponding national health manpower requirements. Implicit in the unified approach is the fact that no single element can be analyzed alone. Consideration of specialty distribution, for example, cannot be isolated from issues of geographic distribution of manpower and access to the health services. It must be examined in the context of physician productivity and task delegation, the composition and mix of local health teams, the utilization of nonphysician health workers and the quality and overall cost of health care. Service of minority groups: A word about socioeconomically disadvantaged students. This issue also interlocks with the problems of specialty and geographic maldistribution. Limited data on ethnic minority and other disadvantaged students show that they are concentrated in a relatively few specialty areas. One-quarter of active black physicians, for example, are engaged in general practice in their primary communities and provide service to an otherwise unserved area. I believe that this trend should
Volume
36
GOVERNMENT AND POSTGRADUATE TRAIN~CDDPER
be supported and encouraged while we increase their ranks with qualified students and well trained physicians.
such gaps as collecting data and developing adequate methodologies for estimating supply.
Utilization of foreign medical school graduates: A sensitive and important facet of our health
Federal Role in Manpower and Postgraduate Training
manpower problem is the complex issue of graduates of foreign medical schools. The debate centers on two primary issues, namely, the quality and the number of such graduates entering the U.S. for training and the practice of medicine. While it appears that the increasing numbers of graduates of foreign medical schools entering and being licensed in the U.S. has served to incite much of the public debate, there is, in fact, an overriding issue of quality. We will support the creation of a truly national qualifying examination to develop and implement a single standard of quality for all medical graduates, foreign as well as U.S., who enter and remain in the U.S. health care system. We shall also evaluate what the revision of immigration law might accomplish toward the stabilization of a federal health manpower policy.
I have no difficulty accepting a federal role to provide technical assistance and to monitor performance. I have considerable reservation about a primary federal role in directing postgraduate training. I suspect that some of you believe that voting federal or public money for postgraduate programs does not mean that you want us to decide what they are to be and how they are to be implemented. I submit that that is naive. It is fashionable today to require “impact” statements-environmental; economic-for new or renewed programs. In proposing your solutions, consider their impact on your independence and on your individuality. Are independence and individuality an important part of quality medicine or health care? If not, we can find a way to distribute you by the numbers. Now for health manpower. House and Senate conferees of the Congress were unable to agree in late December 1974 on new health manpower legislation to replace the Comprehensive Health Manpower Act of 1971, which expired on June 30, 1974. This task was postponed for future years. I cannot predict which manpower bill will be passed by Congress. What I can predict is that it will contain elements addressed to the problems of geographic distribution, specialty and total physician shortages, capitation, the effective delivery of primary care, and the tough question of graduates of foreign medical schools. A new area of concern in the area of manpower will be the potential problems of inadequate supply, overutilization and worsening manpower distribution brought on by the advent of national health insurance.
Role of the Private Sector Many other specific and technical items will need to be considered before final decisions are made on the new federal program-the fate of capitation, the use of student scholarships, the concept of the National Health Service Corps, to mention a few. I would prefer that the private sector take the lead in solving these issues. I believe that specialty organizations like yours can play a major role in accurately determining specialty supply and manpower needs. However, these can only be effectively done in the context of the total manpower picture. Whenever members of the private sector are unable to, or fail to, address important aspects of the problem, you can be sure that someone will suggest that the federal government should do it. We shall try to help fill in
October 31, 1975
The American Journal ot CARDIOLOGY
Volume 36
557
