2017 HSC Section 2 - Practice Management

His second concern involves the present resident work- force, in that “young people are emphasizing lifestyle more than they did previously”. Additionally, regulations on resident work hours have decreased productivity com- pared to past generations. 11 Although debate exists, oth- er authors have voiced concerns that decreasing resident work hours can impact surgical training experience. 12–14 Dr. Pillsbury is also concerned that some forces within our specialty tend to overestimate the size of our group to increase our perceived political power on the federal policy level. He believes this is short-sighted and only serves to hurt our specialty by reducing our actual num- bers and decreases our ability to train future residents. Dr. Pillsbury agrees that the future supply of otolaryng- ologists will be less than adequate and improvements in technology and surgical applications will only increase demand and make this shortage more acute (H. Pills- bury, personal communication, February 3, 2014). To highlight the importance of these issues, the National Ambulatory Medical Care Survey added a set of ques- tions examining physician workforce issues in 2013. “Fueled in part by changes in the delivery system, there is strong interest in understanding the dynamics of prac- tice redesign and how team-based medical care is actual- ly delivered.” 15 National workforce study databases project future supply and demand for physicians, and most conclude that there is currently a shortage of physicians in the United States and also conclude that the deficiency is increasing. Factors cited that exacerbate this shortage include increased population growth, an aging popula- tion, and economic and health policy factors. This issue is made more complex by changes in physician demo- graphics, trends in retirement, and medical student and resident training capacity. An additional unknown is what the future role and scope of nonphysician health care providers such as advanced practice registered nurses and physician assistants (PAs) will be. Physician workforce analysis and reform are chal- lenging. Political, socioeconomic, and physician autono- my issues all interact to complicate the discussion of what represents the optimal or even an adequate physi- cian workforce. Questions pertaining to what is a full- time practice and what constitutes a part-time practice, comparisons of academic and private practices, male as opposed to female physician lifetime productivity, and the perceived generalist–specialist imbalance 12 all polar- ize the debate. The major focus of workforce reforms should be to optimize the training of the future work- force within any given specialty and guide leaders to increase emphasis on areas for which more background and training are warranted and create policies to incen- tivize a more optimal distribution of care. 16 The US health care system, with the passage of the ACA, is evolving at an increasingly rapid pace. In gener- al, the structure of health care delivery is moving toward larger and more integrated systems. The tradi- tional independent physician’s practice is being replaced by contractual arrangements among hospitals or large groups of clinicians. The financing of medical care is changing due to federal legislation, meaningful use, and

DISCUSSION Physician Workforce Analysis and Reform Physician workforce analysis and reform presents extraordinary challenges. To begin to address these chal- lenges, we need to know where we currently are in terms of supply, demand, and infrastructure to deliver these services. Although debate continues, most believe that we currently have a gap between the supply of oto- laryngologists and patient demand; it is further believed that the underservice gap is increasing over time. There is also agreement that our current health care infra- structure is inadequate to meet current demand, and even more inadequate if we consider the additional demand of an aging population and the predicted effects of the ACA. Division exists on the size of this underservice gap and how best to mitigate future deficiencies. In discus- sions with otolaryngology leaders, Michael Maves MD, MBA (past Executive Vice President of the AAO-HNS and past Chief Executive Officer and Executive Vice President of the AMA) believes the otolaryngology work- force is markedly underserving current US need and that this situation, under existing policy, will only wors- en. “What is currently needed is a true snapshot of cur- rent services to guide our future endeavors” (M. Maves, personal communication, January 29, 2014). David Kennedy, MD (former Chair of the AAO-HNS PRC) believes that we, as a specialty, cannot afford to wait for perfect data. He believes the data have been derived from the most recognized sources and the prima- ry issues are not the absolute numbers but whether the current otolaryngologists to population ratio and the cur- rent scope of practice are correct for the US health care system. He is concerned that this ratio is decreasing, especially in the face of an aging population, and is con- cerned by the effect the ACA will have on that ratio. Evi- dence from multiple data sources indicates that this ratio has decreased and that this trend will continue. “Under all scenarios, a shortage of otolaryngologists by 2025 is predicted, even allowing for the expectation that mid-level providers will provide lower intensity services within the specialty.” 9 He agrees that generational life- style preferences, an aging workforce, payment changes, and potential downstream effects of resident work hour limitations are difficult to quantify, but certainly need to be considered when future projections are prepared. He also believes that this gap cannot be corrected by increasing residency training alone, but that increase should be coupled with changes to the structure of cur- rent residency training through shortening the length of training or earlier subspecialization. 10 Harold Pillsbury, MD (past President of the Triolog- ical Society and the ABO) has grave concerns regarding diluting our otolaryngology residency programs by potentially developing a two-tiered residency or a prima- ry certificate program. He notes that “funding for resi- dents encompasses only five years or first certification. It would be difficult to envision how we could support a five year residency with the present paradigm of funding from the Centers for Medicare and Medicaid Services.” 11

Laryngoscope 126: October 2016

Hughes et al.: Otolaryngology Workforce Analysis

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