The Buck Stops Here

RICHARD K. ALBERT

Department of Medicine, University of Colorado Health Sciences Center and Denver Health Medical Center, Denver, Colorado

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The only function of economic forecasting is to make astrology look respectable.

John Kenneth Galbraith

In 1995 the American Thoracic Society, the American College of Chest Physicians and the Society of Critical Care Medicine formed a Committee on Manpower for the Pulmonary and Critical Care Societies to address workforce issues. The Committee commissioned a private consulting firm to assess the current and future supply of, and demand for, pulmonary and critical care physician services in the United States. The resulting study has recently been published (1). The major findings were that the supply of physicians trained in pulmonary and/or critical care will remain constant relative to the present demand until approximately 2007; after 2007 the demand will grow rapidly while the supply will remain unchanged; and the main contributor to this progressive imbalance is the effect that aging of the United States population will have on the utilization of health care resources. How should the pulmonary and critical care community respond to these findings?

The first thing that can be said with some certainty is that the results of this study should not prompt loud calls to increase the number of fellows being trained in pulmonary and/ or critical care (the comments in this essay are my personal views and they do not represent the views of the American Thoracic Society). While this may seem like a paradoxical conclusion, it derives from a consideration of the variables that must be included in any model designed to estimate future workforce supply and demand. For example, future supply will obviously relate to the number of training slots available, but will also depend on physician income and working conditions relative to those of other professions, foreign medical graduate policies, decisions concerning who is qualified to deliver critical care services (i.e., hospitalists versus intensivists versus non-physician providers), the size of the young adult population and the extent to which premedical and medical training are subsidized (2). Demand will depend on the size and age distribution of the population, consumer income and education, consumer and employee decisions regarding insurance coverage, Medicare/Medicaid reimbursement policies, managed care policies, tax treatment of employee-based insurance programs, and biomedical research subsidization, among other considerations (2). Although some of these variables can be estimated rather precisely, most cannot. Accordingly, the accuracy of any model must be viewed with skepticism. History would support this skepticism, as in the 1980s and 1990s numerous studies led to a broad consensus that a surfeit of medical subspecialists was being trained, that subspecialist supply would outstrip demand by the year 2000, and that there was a future need for more primary care physicians. None of these predictions has proven true and, if anything, the subspecialists presently seem to be in short supply, and primary care jobs seem to be decreasing.

Calls for increasing the number of pulmonary and critical care fellows should also be weighed against a concern that the consequences of a potential error are considerable. If one or more of the above variables changes in an unforeseen fashion such that supply is increased or demand is reduced compared with those predicted by Angus and colleagues (1), a decision to increase subspecialty training now could produce a future workforce that is saturated with pulmonary and critical care physicians who are deeply in debt and unable to find jobs (as is presently the case in several European countries). Accordingly, all that I can conclude from this first pulmonary and critical care workforce study is that it should prompt periodic reassessments of these predictions, as well as other selected economic indicators of the market place such as physician salaries and job availability. The results should also stimulate other subspecialties to examine their workforce predictions, because the argument to increase subspecialty training will be far stronger if insufficient future supply is found to be a generalized prediction across many disciplines.

Even if subsequent studies support Angus and colleagues' predictions (1), the pulmonary and critical care community will have to become far more active in educating the public and their elected representatives about the need for these services before any increases in training subsidies will be realized. Although numerous nongovernmental factors will shape the supply and demand of the future workforce, few of these can be altered by intent (see above). Many of the remaining factors, however, will be determined by specific policies that are shaped by the political philosophies of those whom we elect, as well as the effectiveness of the lobbying effort that occurs at the time these policies are developed. With federal, state and local governments projected to contribute over $620 billion to health care in 2001 (more than 40% of the total expenditure) (3), attempts to reduce health care financing will be on the agenda of every governmental body with authority over any type of health care spending for years to come. Pulmonary and critical care physicians should be involved in these discussions.

The financial stability of the Medicare program is threatened in part because the aging United States population is increasing the utilization of health care resources to an extraordinary extent (4). Only two options emerge if the program is to be sustained: increase taxes, or reduce expenses. Reducing expenses can be accomplished by decreasing the number and types of services provided, delaying the age at which coverage begins, shifting part of the program's funding to private sources (possibly as a function of need), and/or by reducing or eliminating the subsidy for graduate medical education. Other potential fixes such as increasing the use of managed care, reducing reimbursements, or improving efficiency are not projected to provide sufficient, long-term reductions in expenses to make them viable options. All of these options are currently being debated, however. In this political climate, requests for increased funding of any sort will be met with serious scrutiny, if not overt laughter. Requests to support the training of more subspecialists, particularly in a single discipline, will, in my opinion, have no chance of receiving serious consideration in Washington, D.C. at this time.

The case for more governmental subsidization of training for pulmonary and critical care physicians is further compromised by the fact that the projected increase in need depends so strongly on the aging of the population. While physicians are ethically obligated to care for each of their patients, politicians are ethically obligated to care for the entire population they serve. Many suggest that there are insufficient funds available to minister to every need of every patient, and that rationing of care should be included in the health care financing debate. Support for this position comes from the fact that 11% of all Medicare expenditures occur in the last month of a patient's life (5), and that the mortality of elderly patients varies widely among counties in the United States without any evident relationship to the extent of the medical care provided (6).

The pulmonary and critical care community should be contributing to this discussion, but we can only do so after we develop our own consensus regarding "indicated" care and rationing. The public will ultimately determine the level of health care they will receive. If we believe that more physicians will be needed to provide "indicated" care to more people, we must do a far better job convincing both the people who might someday be the recipients of this care, and the politicians who will guide its financing, that these services will be worth the cost. The buck stops with us.

	Footnotes

Correspondence and request for reprints should be addressed to Richard K. Albert, M.D., Denver Health Medical Center, 777 Bannock, MC 4000, Denver, CO 80204-4507.

	References

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1. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr.. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA 2000; 284: 2762-2770 [Abstract/Free Full Text].

2. Congressional Budget Office. Medicare and Graduate Medical Education. Washington, DC: United States Government Printing Office; Sept, 1995. p. 24-25.

3. Smith S, Heffler S, Freeland M, National Health Expenditures Projection Team. The next decade of health spending: a new outlook. Health Affairs 1999;18:86-95.

4. Fuchs VR. Health care for the elderly: how much? Who will pay for it? Health Affairs 1999; 18: 11-21 . [Abstract]

5. Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med 1993; 328: 1092-6 [Abstract/Free Full Text].

6. Wilensky GR, Newhouse JP. Medicare: what's right? What's wrong? What's next? Health Affairs 1999; 18: 92-106 .