How many physicians does a hospital, health network, medical group or other organization need?
Market changes are altering the answer to that question, and medical staff planners must modify their assumptions and methods accordingly.
In general, the staffing response to managed care has been to employ more primary-care physicians and fewer specialists than typically are used in traditional fee-for-service markets. For organizations faced with increasing managed care, the challenge lies in determining precisely how many physicians-primary-care and specialists-are necessary to meet strategic goals.
A logical place to begin is with a review of existing physician-need-per-population surveys and studies. A comparison of these studies shows the transition that has taken place from the days of specialty-dominated fee-for-service physician staffing to the primary-care gatekeeper system of today.
The Graduate Medical Education National Advisory Committee study of 1980 offers a convenient point of comparison between old staffing models and new. The GMENAC's physician-need-per-population ratios were made in a fee-for-service context with the objective of ensuring accessibility and availability of physicians. The study concluded that the U.S. would need a physician population composed of 36% primary-care physicians and 64% specialists by 1990-almost exactly the ratio that exists today. Though dated, the GMENAC numbers are still commonly used by medical staff planners as a starting point.
Not surprisingly, the GMENAC's ideal physician-to-population ratios are generally higher than those currently used by a variety of managed-care organizations. Few markets today are likely to need more physicians than those prescribed by the committee. Indeed, in our experience a useful rule of thumb when calculating the optimum number of specialists a medical group or other provider organization may need to service a managed-care patient group is to divide the GMENAC numbers in half.
A practical physician-requirement formula was developed by Lanis L. Hicks and John K. Glenn, then with the University of Missouri, in the late 1980s. It calculates physician need based on the average number of physician encounters a population generates for a particular specialty divided by the number of encounters that specialty can handle.
For example, a hypothetical population of 100,000 generating three patient encounters per person per year in a specialty that can handle an average of 3,000 encounters annually would need 100 physicians in that specialty, or one specialist per 1,000 people. Physician encounters per population are compiled by the National Center for Health Statistics. Statistics on average annual patient encounters handled per specialty are generated from Medical Group Management Association survey data.
Another useful ratio was developed by principals of the Longshore and Simmons consulting firm in the 1990s. It combines the averages of different formulas and managed-care physician usage patterns to arrive at a base rate per specialty. It's also helpful to note that about 45% of HMO physicians are in primary care, with a commonly targeted distribution rate of 50% family practice, 25% internal medicine and 25% pediatrics.
The GMENAC study and a variety of physician-need formulas and managed-care physician usage patterns can be used as a frame of reference for medical staff planners attempting to get a fix on their own staffing requirements.
Since the gist of most current medical staff plans is a projected need for additional primary-care physicians and fewer specialists, implementing a plan can be practically and politically difficult. Guidelines for implementation include:
Setting goals. A growing number of multispecialty groups are being formed today by health networks, medical management firms or physicians themselves from the bottom up-beginning with primary-care doctors and adding specialists-to capture capitated patients. Other organizations are rushing to recruit primary-care physicians in response to patient-satisfaction surveys critical of physician inaccessibility. Whatever the motive, organizations must set clear physician staffing goals based on one or a combination of objective staffing formulas.
Flexibility. Projected physician-need rates and current usage patterns are a starting point, not cast-in-stone commandments. Physician-need rates will vary based on the demographics of different patient groups, managed-care penetration and other local market conditions.
Education. A provider network overbalanced with specialists or generalists will ultimately hurt the physicians involved, usually by overtaxing the resources available under managed care. Make physicians understand the changes taking place in the market and why such changes require new staffing models.
Selectivity. Organizations serving managed-care populations are becoming more selective in their recruitment of physicians, specialists in particular. Specialists with a variety of skills are at a premium because they reduce the total number of specialists required. A general surgeon who also does endoscopes reduces or eliminates the need for a gastroenterologist. A rheumatologist might be brought into the group as a general internist who also can assume rheumatology referrals. It behooves provider groups to recruit, and specialists to become, utility players.
Data. Physician encounters per population, primary-care physician referral patterns, requests for particular services by patients, patient migration and the age and anticipated retirement rates of existing physicians are all important parts of the medical-staffing equation. The better the data available, the more targeted and strategic a medical staff plan will be.
The need for changing physician requirement formulas comes at a time of national debate over physician supply. Whether or not the U.S. has too few or too many physicians is irrelevant, however, to planners staffing particular provider networks in particular markets. More important is developing a blueprint for the number and mix of physicians who will be needed in your market and then marshaling the resources and political support necessary to carry out the plan.
Merritt, Hawkins & Associates is a national healthcare staffing firm based in Irving, Texas.