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How to determine the need for MDs by specialty.

THE FISCAL INCENTIVES INHERENT IN MANAGED CARE, and the desire by medical groups and hospitals to protect their income, will force them to commit to more detailed analyses of their physician manpower needs by clinical specialty. These reports will recommend, depending on the clinical discipline, whether to add physicians or close their medical staffs to other doctors. Undertaking such studies are more critical than ever before, due to the increasing supply of qualified specialists seeking hospital privileges and the growth in enrollment of HMOs and other similar arrangements.

Although past debates about appropriate medical staff credentialing Credentialing is the administrative process for validating the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy.  frequently related to "due process," the focus of these discussions are predicted to shift in the future toward the numbers--whether the hospital has an inadequate, sufficient, or excess number of physicians available by specialty to appropriately serve its community. Or, to a somewhat similar question of whether an HMO HMO health maintenance organization.

A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial,
 has the suitable number of doctors by specialty in its closed panel to appropriately meet the patient care needs of its subscribers.

Most hospitals in the United States Lists of hospitals for each U.S. state:

  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
 historically have opted for an open medical staff policy and have extended privileges to any qualified physician. However, there are substantive arguments to suggest several advantages of a closed staff by specialty:

(a) to enhance the quality of patient care in a community by reducing unnecessary services (particularly in a fee-for-service environment) that might be generated by a doctor who has less than a sufficiently busy practice to generate his or her projected income;

(b) to permit the members of the medical staff and its related facility to profit by minimizing the number of readily available competitors (e.g., conspiring to restrain trade in violation of Section I of the Sherman Antitrust Act Sherman Antitrust Act, 1890, first measure passed by the U.S. Congress to prohibit trusts; it was named for Senator John Sherman. Prior to its enactment, various states had passed similar laws, but they were limited to intrastate businesses. ).

Do more doctors generate more admissions?

A topic of considerable interest has been whether by simply adding more physicians to a hospital's medical staff that this action will generate significant increases in the facility's admissions, and emergency department and other ambulatory care ambulatory care
Medical care provided to outpatients.

ambulatory care,
n the health services provided on an outpatient basis to those who can visit a health care facility and return home the same day.
 visits. Conventional wisdom suggests that the more practicing physicians per 1,000 persons available, the more hospital admissions and outpatient outpatient /out·pa·tient/ (-pa-shent) a patient who comes to the hospital, clinic, or dispensary for diagnosis and/or treatment but does not occupy a bed.

 visits should be forthcoming--thereby bringing about increases in the organization's revenue stream.

An earlier study (1) proposed that when there was more than one physician per 625 service area residents, utilization rates for inpatient inpatient /in·pa·tient/ (in´pa-shent) a patient who comes to a hospital or other health care facility for diagnosis or treatment that requires an overnight stay.

, emergency, and referred ambulatory care services tended to level off or decrease. The explanation was that when competition for patients among physicians heats up, doctors offer a broader spectrum of services in their own offices. A pertinent example is more primary care doctors now offering early evening office hours office hours, See business hours.
 rather than referring their HMO patients, who call after 4:00 p.m., to the hospital's emergency department. Therefore, additional research could confirm that once a minimum "sufficient" number of physicians are available to meet the patient care needs of a specific service area population, it could well be to the fiscal advantage of the local doctors and the hospital to limit the number of MDs available.

Dynamics of physician manpower projections

An oversupply o·ver·sup·ply  
n. pl. o·ver·sup·plies
A supply in excess of what is appropriate or required.

tr.v. o·ver·sup·plied, o·ver·sup·ply·ing, o·ver·sup·plies
 of physicians in most areas of the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  has caused a heating up of competition among MDs, and among doctors and hospitals for ambulatory care revenues. It has already led to numerous changes related to where and how American health American Health Inc. is a company that manufactures health supplements. It is located in Holbrook, New York. One of its products is labeled the "Chewable Original Papaya Enzyme" with the attached registered trademark, "The 'After Meal Supplement'".  care services are delivered. The increased number of doctor-sponsored ambulatory surgery ambulatory surgery
Surgery performed on a person who is admitted to and discharged from a hospital on the same day.

ambulatory surgery,
 and imaging centers that opened during the 1980s illustrates how physicians are more actively competing with hospitals for third-party reimbursement Reimbursement

Payment made to someone for out-of-pocket expenses has incurred.
. In the 1990s, the tremendous growth in managed care enrollment has curtailed provider revenues in additional ways by placing a damper damp·er  
1. One that deadens, restrains, or depresses: Rain put a damper on our picnic plans.

2. An adjustable plate, as in the flue of a furnace or stove, for controlling the draft.
 on the demand for specialty physician services and hospital inpatient utilization. (2,3)

Based on the assumptions that 40 to 65 percent of all Americans will receive care from integrated managed care networks, and that health services health services Managed care The benefits covered under a health contract  will be reasonably accessible, it was projected that by the turn of the century there will be an overall surplus of about 165,000 patient care physicians in the United States. (4) Furthermore, these estimates suggest that by the year 2000 the demand and supply for primary care physicians can be expected to be in a relative balance, while the supply of specialists will outstrip out·strip  
tr.v. out·stripped, out·strip·ping, out·strips
1. To leave behind; outrun.

2. To exceed or surpass: "Material development outstripped human development" 
 the requirement needed for these doctors by more than 60 percent.

With the pivotal issues in many communities becoming a growing surplus of doctors and more constrained con·strain  
tr.v. con·strained, con·strain·ing, con·strains
1. To compel by physical, moral, or circumstantial force; oblige: felt constrained to object. See Synonyms at force.

 reimbursement, hospitals have expended ex·pend  
tr.v. ex·pend·ed, ex·pend·ing, ex·pends
1. To lay out; spend: expending tax revenues on government operations. See Synonyms at spend.

 additional resources to study their fixed and variable costs by DRG DRG,
n the abbreviation for diagnosis-related group.


see dorsal respiratory group.

DRG Diagnosis-related group Managed care A unit of classifying Pts by diagnosis, average length of hospital stay, and
 and by physician, so when negotiating with HMOs, these facilities can price their services competitively. By engaging in this process, hospitals determine which specialties and specific physicians generate fiscal surpluses and losses for them, which, in turn, can affect an institution's credentialing process for medical staff privileges staff privileges Admitting privileges The rights that a health professional has as a member of a hospital's medical staff, which includes hospitalization of private Pts, participation in committees, and in decisions relevant to the hospital's future. .

This current "glut glut pronounced as rut, slut Vox populi An excess of a service or skilled labor in a particular area. See Physician glut. " in the supply of physicians is also creating an increasing concern to doctors, since their disposable income disposable income

Portion of an individual's income over which the recipient has complete discretion. To assess disposable income, it is necessary to determine total income, including not only wages and salaries, interest and dividend payments, and business profits, but also
 is declining adjusted for the consumer price index. (5) In fact, many physicians are aggressively seeking ways to expand their market share to generate additional revenues. Meanwhile, several types of studies to evaluate the need to add doctors in specific disciplines are receiving higher priority from the senior leadership of various networks, because hospital revenues are so closely tied to the composition, and the admission and utilization patterns, of their medical staffs.

Analysis purposes and limitations

In the sense that physician manpower planning studies must consider the interests of the community foremost, and thereafter its doctors and hospitals, this article outlines an approach used to determine whether a service area of a predetermined pre·de·ter·mine  
v. pre·de·ter·mined, pre·de·ter·min·ing, pre·de·ter·mines
1. To determine, decide, or establish in advance:
 size and composition offers an inadequate, sufficient, or excess number of physicians by clinical specialty. Although these methodologies or steps described herein are most frequently used by hospitals and medical groups, similar endeavors are employed by managed care plans to conclude whether they have enough, need additional, or could rely on fewer physicians in their panels to appropriately serve their subscribers.

This type of physician manpower analysis is more useful where there are relatively significant disparities between the projected demand and supply within a specific clinical specialty, rather than estimating whether a multi-specialty group, for example, needs an eleventh In music or music theory an eleventh is the note eleven scale degrees from the root of a chord and also the interval between the root and the eleventh.

Since there are only seven degrees in a diatonic scale the eleventh degree is the same as the subdominant and the interval
 or twelfth general internist internist /in·tern·ist/ (in-ter´nist) a specialist in internal medicine.

A physician specializing in internal medicine.
 to join their practice. In the latter case, the percent changes in departmental volumes and in productivity per doctor over the last three years might be more critical indicators in this decision-making process than the following methodologies outlined.

Methodologies to determine need

A hospital, medical group, or HMO can utilize several methods to evaluate whether it should decrease or add physicians to its staff. The approaches proposed must be considered in the context of several variables: the region's population growth or decrease; the service area's demographics The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data. , not limited to such variables as age and income distribution; the type of third-party reimbursement available to its residents; the clinical resources readily accessible, compared to existing patient case mix; the composition by clinical specialty and by age distribution of the physicians currently practicing in the community; and, any relevant federal and state planning and reimbursement rules and regulations impinging on the community's projected physician manpower needs.

Hospitals (somewhat modified for medical groups and HMOs) use the following methodologies or steps to determine physician needs:

1. Determine the composition, utilization patterns, and cost per case adjusted by case mix intensity of each member of the hospital's existing medical staff and each of its clinical departments and sections

2. Individually interview all key members of the hospital's medical staff and the governing board's officers

3. Mail a questionnaire to each member of the medical staff to inquire in·quire   also en·quire
v. in·quired, in·quir·ing, in·quires

1. To seek information by asking a question: inquired about prices.

 whether any physician(s) should be added to 28 or more clinical specialties and subspecialties

4. Calculate the physician-population ratios by clinical specialty using various models. Reaching valid quantitative determinations is a complex process as HMO reimbursement incentives are perceived to result in a decreased demand for all but primary care services.

5. Project which specialties should be open or closed to meet community, hospital, or subscriber needs using data and information gathered, along with reasonable judgment and experience

Step 1: Quantitative analysis Quantitative Analysis

A security analysis that uses financial information derived from company annual reports and income statements to evaluate an investment decision.


The first step in determining medical staff composition and utilization patterns for a hospital, medical group, or HMO is to collect quantitative data by department and by subspecialty subspecialty,
n a limited portion of a narrowly defined professional discipline. E.g., surgery is a specialty of medicine and pediatric vascular surgery is a subspecialty.
 that includes each physician's age; board specialty status; type of appointment; office location by zip code zip code

System of postal-zone codes (zip stands for “zone improvement plan”) introduced in the U.S. in 1963 to improve mail delivery and exploit electronic reading and sorting capabilities.
 or census tract A census tract, census area, or census district is a particular community defined for the purpose of taking a census. Usually these coincide with the limits of cities, towns or other administrative areas and several tracts commonly exist within a county. ; and, the number of admissions, patient days, average length of stay, operative OPERATIVE. A workman; one employed to perform labor for another.
     2. This word is used in the bankrupt law of 19th August, 1841, s. 5, which directs that any person who shall have performed any labor as an operative in the service of any bankrupt shall be
 procedures, and deliveries during each of the past three years. Most hospitals are able to provide for every physician data on his or her average cost per discharge adjusted by case mix intensity, information that is significant in assessing whether the doctor is a positive or a negative producer in fiscal terms for the health care organization.

This proposed data collection process can be complicated by, say, a four-member single-specialty practice admitting patients to the hospital as a "group," rather than as individual physicians. Even with such limitations, these work sheets should provide an overall profile of the department or subspecialty; often illustrate significant differences in practice patterns among subspecialists in the same clinical discipline; and, frequently provide pertinent trend data that can influence the study's final conclusions and recommendations.

Summarizing these departmental and subspecialty data for the most current year and then preparing a quartile Quartile

A statistical term describing a division of observations into four defined intervals based upon the values of the data and how they compare to the entire set of observations.

Each quartile contains 25% of the total observations.
 analysis (i.e., those physicians responsible for the first 25 percent, 50 percent, and 75 percent) by admissions, patient days, deliveries, and operative procedures can pinpoint which departments and physicians generate high or low utilization. From a hospital's prospective, it is highly desirable that there be a large number of physicians responsible for 50 percent or more of the facility's admissions and operative procedures.

Each doctor within the medical staff must be evaluated in terms of full-time equivalents Full-time equivalent (FTE) is a way to measure a worker's involvement in a project, or a student's enrollment at an educational institution. An FTE of 1.0 means that the person is equivalent to a full-time worker, while an FTE of 0.5 signals that the worker is only half-time.  (FTEs) to determine physician-population ratios. It is critical to accurately estimate what might be considered the number of FTE FTE Full-Time Equivalent
FTE Full-Time Employee
FTE Full-Time Equivalency
FTE Full Time Employment
FTE Foundation for Teaching Economics
FTE Full Time Enrollment
FTE For the Enterprise (SQL)
FTE Fund for Theological Education
 physicians available in a department or subspecialty. Gaining agreement that there are, for example, 5.5 FTE orthopedic orthopedic /or·tho·pe·dic/ (-pe´dik) pertaining to the correction of deformities of the musculoskeletal system; pertaining to orthopedics.  surgeons at the hospital is generally straightforward at the beginning of the study, before the possible implications to the individual practitioners of such an approximation approximation /ap·prox·i·ma·tion/ (ah-prok?si-ma´shun)
1. the act or process of bringing into proximity or apposition.

2. a numerical value of limited accuracy.
 are fully known.

Step 2: Personal interviews

To determine whether there are too many, just enough, or too few physicians by clinical specialty, 15- to 30-minute interviews should be conducted with all key doctors who might be directly affected by the study's findings and recommendations. Interviews with each officer of the hospital's governing board Noun 1. governing board - a board that manages the affairs of an institution
board - a committee having supervisory powers; "the board has seven members"
 and some local industrial leaders can be critical in successfully formulating most physician development plan studies, since they can offer a broader overview of where there may be actual or perceived deficiencies in the community's overall health delivery system.

Most frequently, a physician interviewee will say at the outset that there are enough specialists or subspecialists in his or her discipline in the region. Surgeons often believe that there are neither enough internists nor family practitioners family practitioner
n. Abbr. FP
See family physician.
 available, while those in medically-oriented disciplines often suggest that additional surgeons are needed.

On the basis of these interviews, almost unanimous agreement is frequently reached that in one or more disciplines either a new clinical subspecialty needs to be established or one to two more physicians in a specific discipline must be added. The latter is often evidenced by the comment that existing doctors in a clinical discipline appear to experience an excess workload--delays in meeting consultation requests and patients being required to wait six to eight weeks for a routine appointment in these physicians' offices.

A summary of these interviews should be sent to the hospital's Chief Executive Officer, President/Chief of the Medical Staff, the Vice President of Medical Affairs, the Governing Board President, and possibly others for review and comment. This process should further ensure the reliability of the information gathered. Thereafter, this summary of interviews should be distributed to members of the hospital's medical executive committee, since this document can be of potential immediate use in their programmatic pro·gram·mat·ic  
1. Of, relating to, or having a program.

2. Following an overall plan or schedule: a step-by-step, programmatic approach to problem solving.

, service, and physician manpower planning efforts.

Step 3: Physician questionnaires

To gauge the entire medical staff's perceptions of the number and type of physicians needed at the hospital, the third step is for a questionnaire to be mailed to each medical staff member, preferably pref·er·a·ble  
More desirable or worthy than another; preferred: Coffee is preferable to tea, I think.

 with a cover letter from the Chief of Staff/President. With a relatively short questionnaire covering 20 to 35 medical specialties Medical Specialties
See also anatomy; disease and illness; drugs; health; remedies; surgery.


the science of the description of glands. — adenographic, adj.
, respondents In the context of marketing research, a representative sample drawn from a larger population of people from whom information is collected and used to develop or confirm marketing strategy.  are asked whether there are enough, too many, or too few doctors in each specialty and subspecialty. A quantitative analysis of the results of those questionnaires returned can be illustrated by using a +1.000 (high priority) to -1.000 (low priority) "need value." A 65 to 85 percent response rate can be expected from this confidential approach. This inquiry also has positive public relations public relations, activities and policies used to create public interest in a person, idea, product, institution, or business establishment. By its nature, public relations is devoted to serving particular interests by presenting them to the public in the most  and political value, and almost always validates the information obtained from the interviews.

Step 4: Physician-population ratios

It is possible to calculate physician-population ratios by clinical discipline having previously determined: (a) the hospital's service area (defined herein as the total population served by the hospital or the medical group, adjusted by a percentage of its market penetration Noun 1. market penetration - the extent to which a product is recognized and bought by customers in a particular market
penetration - the act of entering into or through something; "the penetration of upper management by women"
 in that area); and, (b) the previously estimated FTEs available in the hospital or medical group by clinical specialty.

This methodology makes a few underlying assumptions such as: the hospital's service area population (e.g., 200,000 persons in region and a facility has a 50 percent market share equals a 100,000 service area population) is comparable to the number of individuals in the community served by the physicians on the hospital's medical staff; and, the physician-population ratios used are neutral in terms of such variables as population density, the age distribution of the patient population, the level of physician productivity, the type of third-party coverage available, and patient incomes being near the national mean.

The appropriate model and physician-population ratios that a hospital might select when establishing its physician development plan has evolved over the last several decades. Early sources used for these purposes were simply estimates provided by specialty groups based on a number of variables unique to that clinical discipline. A far broader reference extensively utilized in the 1980's to determine MD manpower needs, which was predicated on needs- and demand-based workforce projections, was the findings and recommendations of the Graduate Medical Education National Advisory Committee (GMENAC) report. (6)

Most recent studies, (7-9) primarily based on the experiences of staff- or group- HMOs or the use of benchmarking techniques in regions where there is a high or low penetration of managed care, have reduced earlier estimates of the total number of physicians needed to serve a given population and have placed a higher priority on training and recruiting more primary care physicians. The reasons for this shift need some explanation: Demand-based planning simply extrapolates future physician utilization levels from the current one and then estimates supply requirements accordingly.

Concurrently using both needs- and demand-based workforce projections can be more accurate, since this approach allows for modifications in terms of potential changes in workloads by specialty; the effects of the fiscal incentives inherent in managed care; and, the increased use of non-physician extenders, such as physician assistants.

By contrast, benchmarking compares the present physician supply in a specific service area with different geographic regions or with a more circumscribed circumscribed /cir·cum·scribed/ (serk´um-skribd) bounded or limited; confined to a limited space.

Bounded by a line; limited or confined.
, organized health care system (e.g., HMO or health network) that has a distinctive staffing pattern. Geographic benchmarking, which is based on physician-hospital referral patterns, also allows for the analysis of a "clinically relevant" doctor supply as this methodology derives its data base from the actual use patterns for specific physician services.

For a service area population of 100,000 persons, Table 1 provides a comparison by clinical specialty of the number of physicians:

* (a) currently available in the United States (Table I, Model A)

* (b) estimates of need reported in the GMENAC study (Model B)

* (c) the staffing of a large HMO with 2.4 million subscribers (Model C)

* (d) the staffing in the Minneapolis region with its high HMO penetration HMO penetration Managed care The proportion of Pts in a geographic region enrolled in an HMO. See HMO.  (Model D)

* (e) the staffing in Wichita, Kansas
For other uses, see Wichita (disambiguation).

Wichita, also known as the Air Capital of the World, is the largest city in the U.S. state of Kansas, as well as a major aircraft manufacturing hub and cultural center.
, where there is a low managed care market penetration (Model E)

In many ways, these five models provide a hospital, physician group, or HMO with some flexibility to match up their objectives and environment with a range of doctor staffing patterns from national averages (185.0 MDs/100,000) to those used in a far more restricted HMO environment (138.4 MDs/100,000).

In utilizing one or more of these five models, the findings that follow could have a significant affect on a physician development plan's final recommendations for a specific hospital, medical group, or HMO:

1. There are significantly more physicians per 100,000 persons now available (Model A) than were previously projected as needed as needed prn. See prn order.  in the 1980 GMENAC study (Model B). The GMENAC study missed its mark with its assumption concerning the entry of international medical graduates into America's graduate medical education pool--many of whom eventually practice in the United States. The difference between the conservative GMENAC forecast of 1,350 new international physicians per year and today's figure of 6,900 new doctors from overseas "is roughly equivalent to the annual output of 44 medical schools, each graduating 125 new physicians per year." (10)

2. Several earlier HMO studies (11-14) reported in the range of 120 to 130 MDs per 100,000 persons, slightly less than used in Model C. Whether this finding is related to HMOs selecting the more favorable fa·vor·a·ble  
1. Advantageous; helpful: favorable winds.

2. Encouraging; propitious: a favorable diagnosis.

 risks, their not including outside or part-time physicians in their FTE calculations, or their heavy reliance on physician assistants and nurse practitioners nurse practitioner
n. Abbr. NP
A registered nurse with special training for providing primary health care, including many tasks customarily performed by a physician.
 needs further research. The large HMO (Model C) staff have significantly less primary care physicians, particularly family practitioners, than the other models depicted de·pict  
tr.v. de·pict·ed, de·pict·ing, de·picts
1. To represent in a picture or sculpture.

2. To represent in words; describe. See Synonyms at represent.
 in this analysis.

The overall evidence is that closed- and staff-type HMOs tend to use general internists rather than family practitioners as their "gatekeepers." Although nationally there are slightly more family practitioners than general internists available (Model A), the Kaiser plan uses almost twice the number with a background in general internal medicine than those more broadly trained in family medicine per 100,000 subscribers. (15)

3. Contrary to the conclusions discussed earlier are the recently published findings from two large (totaling 613,354 subscribers), mature staff-model HMOs (Group Health Cooperative Group Health Cooperative, based in Seattle, Washington, is a consumer-governed nonprofit healthcare system. Established in 1947, it today provides coverage and care for about 540,000 people in Washington and Idaho and is one of the largest private employers in Washington.  of Puget Sound Puget Sound (py`jĕt), arm of the Pacific Ocean, NW Wash., connected with the Pacific by Juan de Fuca Strait, entered through the Admiralty Inlet and extending in two arms c.  in the Seattle area and Group Health, Inc., of Health Partners in the Minneapolis area) to determine precise specialty specific physician staffing ratios to see whether these managed care plans use fewer physicians than the fee-for-service sector. (16) These two HMOs provided on the average an equivalent of 180 physicians per 100,000 enrollees, which is consistent with the national average (Model A) and far above figures that typically are reported in the literature for managed care plans (Model C).

The major reason for this difference being that these two plans use 173.1 percent more family practitioners per 100,000 enrollees than the 2.5 million subscriber HMO illustrated by Model C. These data suggest that as a greater portion of America's population migrates to managed care (e.g., those eligible for Medicare and Medicaid Medicare and Medicaid

U.S. government programs in effect since 1966. Medicare covers most people 65 or older and those with long-term disabilities. Part A, a hospital insurance plan, also pays for home health visits and hospice care.
), HMO physician staffing may come to resemble, in terms of MD use patterns, more closely the traditional fee-for-service sector than is currently envisioned for managed care, except for the greater use of generalist gen·er·al·ist
A physician whose practice is not oriented in a specific medical specialty but instead covers a variety of medical problems.

 physicians and physician extenders physician extender A popular term for a trained health professional who provides quasi-autonomous health care under a particular physician's license Examples Physician assistant, nurse practitioner, etc. See Physician assistant, Nurse, Nurse practitioner. .

HMO subscriber utilization patterns might eventually illustrate an even greater number of generalist and fewer specialist physician visits per annum Per annum

, and less high-technology diagnostic testing Diagnostic testing
Testing performed to determine if someone is affected with a particular disease.

Mentioned in: Von Willebrand Disease
 and therapeutic procedures somewhat similar to those patient care approaches experienced in the quasi-private, quasi-public German health care system. (17) What is worrisome about these recent findings is that recent warnings of a physician oversupply physician oversupply Physician glut Medtalk An excess of physicians in a particular geographic region or specialty. Cf Manpower shortage, Physician shortage area.  in the United States and the recommended severe corrective cor·rec·tive
Counteracting or modifying what is malfunctioning, undesirable, or injurious.

An agent that corrects.

 remedies could actually be somewhat exaggerated. However, there is uniform support to the view that specialist surpluses can continue to be expected unless these training programs are curtailed. (18-21)

4. Increased enrollment in HMOs with capitated payment will result in intensifying in·ten·si·fy  
v. in·ten·si·fied, in·ten·si·fy·ing, in·ten·si·fies
1. To make intense or more intense:
 what we already recognize nationwide as a "glut" of specialists. There are more than twice the number of general surgeons General surgeon
A physician who has special training and expertise in performing a variety of operations.

Mentioned in: Appendectomy
 available per 100,000 persons in the United States (Model A) than are utilized by the large HMO with 2.4 million subscribers (Model C). Also, managed care plans staff with significantly fewer psychiatrists This list includes notable psychiatrists.

Individuals listed below are all physicians, and are board certified by the American Board of Psychiatry and Neurology, or are members of the American Psychiatric Association, or the Royal College of Psychiatrists in the United Kingdom, or
 than are generally available in the fee-for-service environment.

5. The Minneapolis region (Model E), which is lauded for its high managed care market penetration, has more physicians per 100,000 persons than might have been forecasted--20.7 percent more than the HMO model (C) and even 16 percent more than the Wichita fee-for-service environment.

6. Finally, there is considerable disparity dis·par·i·ty  
n. pl. dis·par·i·ties
1. The condition or fact of being unequal, as in age, rank, or degree; difference: "narrow the economic disparities among regions and industries" 
 among the ratios within a number of clinical disciplines when comparing one model to another, which in some cases could be related to an interchange of skills (e.g., many medical subspecialists now spend a significant amount of time practicing general internal medicine).

Regardless of the possible limitations in using a physician-population ratio-type analysis (e.g., due the age distribution of the population, being a tertiary tertiary (tûr`shēârē), in the Roman Catholic Church, member of a third order. The third orders are chiefly supplements of the friars—Franciscans (the most numerous), Dominicans, and Carmelites.  referral center), this methodology in most studies replicates the general findings of the interviews and questionnaires. It also provides one additional source of information when arriving at specific conclusions and recommendations. Implementing a physician development study based only on physician-population ratios and not on the information obtained from other methods (Steps 1-3) outlined herein, could well lead any organization to make serious mistakes in its MD manpower planning efforts.

Step 5: Composite summary

Having completed the four methodologies, the hospital or medical group should develop a summary by clinical discipline (Table 2) that outlines the study's major findings and recommendations. After this report has been reviewed by the organization's trustees and then either approved as submitted or modified, it should serve as the hospital's physician development plan. This study should then be used to guide any additions or modifications in appointments to the facility's medical staff in the future.

In tackling the question of how many active staff members by clinical discipline a hospital should have, the trustees' foremost consideration should be to meet community health care needs. The second criteria is to resolve the deficits by clinical discipline that have been confirmed by at least three of the four methodologies. Table 2 illustrates that there is one hematologist/oncologist, who is the second most active practitioner in terms of patient days. There is also agreement on the basis of interviews, questionnaires, and the physician-population ratios that a second medical oncologist medical oncologist  Oncology An oncologist who diagnoses and treats cancer with chemotherapy, hormones, biologicals, or immunologic agents; the MO becomes a cancer Pt's de facto primary care giver, and coordinates treatment provided by other specialists.  is needed. The medical staff and the hospital must join forces to recruit potentially qualified candidates to fill such deficits, where there is overwhelming evidence that a physician need exists.

The next priority might center on potentially tampering tampering The adulteration of a thing. See Drug tampering.  with the geographic distribution of the primary care physicians' offices. Recommendations to add a primary care physician can be made on the basis of locating the doctor's office on the periphery periphery /pe·riph·ery/ (pe-rif´er-e) an outward surface or structure; the portion of a system outside the central region.periph´eral

 of the hospital's service area in order to increase the facility's market penetration. There could be some doubt about whether the courts would uphold up·hold  
tr.v. up·held , up·hold·ing, up·holds
1. To hold aloft; raise: upheld the banner proudly.

2. To prevent from falling or sinking; support.

 such a recommendation, but a positive finding on location should encourage most young internists to locate an office in a specific geographic area where there is an obvious need for their services.

A hospital could also often justify adding another physician to its active staff, when an existing practitioner nears the age of 65. This determination could be based on older physicians usually expressing more interest in leisure time and often are less familiar with recent advances in medicine.

When the hospital's clinical strengths and utilization patterns suggest that several single or multi-specialty groups are the backbone of the institution, the analyses and the development of appropriate recommendations as described earlier can become more politically intricate. The most frequent issue relates to a large primary care group desiring to add specialty members to its staff to meet its own, rather than the hospital or the community's needs. Another problem is an increasing number of hospitals experiencing HMO subscribers who must change doctors in order to be admitted to the facility of their choice.

How to potentially avoid legal sanctions Sanctions is the plural of sanction. Depending on context, a sanction can be either a punishment or a permission. The word is a contronym.

Sanctions involving countries:

By annually updating recommendations on the number of physicians required by clinical discipline to meet community needs, a medical staff and its hospital is able to adjust its pool of doctors appropriately. Once the governing board has approved a physician development plan, the hospital must still follow due process in evaluating physicians for a medical staff appointment and be able to justify its physician staffing decisions to ensure the integrity of its credentialing process and avoid adverse court decisions.

The legality le·gal·i·ty  
n. pl. le·gal·i·ties
1. The state or quality of being legal; lawfulness.

2. Adherence to or observance of the law.

3. A requirement enjoined by law. Often used in the plural.
 of a hospital's closed medical staff by specialty will continue to be challenged in the courts and the methodologies described in this article--and each possible contentious case--must be reviewed with the organization's counsel. Those areas that can be expected to generate the most legal controversies include: Whether a broad spectrum of managed care plans will use family practitioners or internists and pediatricians as their prime "gatekeepers;" whether, in the long-run, the fiscal incentives inherent in managed care will result in a more frugal fru·gal  
1. Practicing or marked by economy, as in the expenditure of money or the use of material resources. See Synonyms at sparing.

2. Costing little; inexpensive: a frugal lunch.
 utilization of physician services; how much demographic factors, type of reimbursement coverage available, and scope of provider resources have an impact on the need for physicians by specialty specific within a defined service area.

However, a hospital policy that accepts qualified applicants in specific disciplines and has chosen, based on reasonable criteria, not to provide applications for an appointment in other specialties, has been considered by the courts, in most states, as being in a defensible de·fen·si·ble  
Capable of being defended, protected, or justified: defensible arguments.


Specialty                      US      GMENAC      HMO
                             Model A   Model B   Model C

Primary care                   --        --        --
Family practice               31.9      33.3      15.6
General internal              25.4      27.8      26.3
Pediatrics                    14.2      12.0      11.1
Medical subspecialties         --        --        --
Allergy                        1.2       0.8       0.9
Cardiology                     5.3       3.1       2.6
Dermatology                    2.7       2.7       2.1
Endocrinology                  0.9       0.8       0.8
Gastroenterology               2.6       2.6       2.8
Hematology/                    2.1       3.6       2.2
Infectious disease             0.7       0.9       0.8
Nephrology                     1.2       1.1       1.1
Neurology                      2.9       2.2       2.2
Pulmonary medicine             2.0       1.4       0.9
Rheumatology                   1.0       0.7       1.2
Surgical specialties           --        --        --
Obstetrics/gynecology         12.4       9.6      11.5
General surgery               11.8       9.4       5.1
Neurosurgery                   1.5       1.1       0.5
Ophthalmology                  6.1       4.7       5.1
Orthopedic surgery             7.1       6.1       5.1
Otolaryngology                 2.9       3.2       3.4
Plastic surgery                1.7       1.1       0.7
Thoracic surgery               0.8       0.8       0.8
Urology                        3.4       3.1       3.2
Hospital-based specialties     --        --        --
Anesthesiology                10.0       8.4       9.0
Emergency medicine             9.4       5.4       6.2
Pathology                      4.6       5.4       5.3
Psychiatry                    13.1      15.3       3.3
Radiology                      6.1       7.1       8.6
Total                        185.0     173.7     138.4

Specialty                    Wichita     MN
                             Model D   Model E

Primary care                   --        --
Family practice               29.0      34.2
General internal              23.4      27.3
Pediatrics                    13.1      14.1
Medical subspecialties         --        --
Allergy                        0.7       1.3
Cardiology                     3.5       4.4
Dermatology                    1.4       2.8
Endocrinology                  0.8       0.8
Gastroenterology               1.3       1.9
Hematology/                    1.2       2.3
Infectious disease             0.8       0.8
Nephrology                     1.1       1.1
Neurology                      2.1       2.5
Pulmonary medicine             1.4       1.6
Rheumatology                   0.4       0.8
Surgical specialties           --        --
Obstetrics/gynecology          8.4       9.2
General surgery                9.6       9.1
Neurosurgery                   0.9       1.3
Ophthalmology                  3.5       5.6
Orthopedic surgery             5.9       7.7
Otolaryngology                 2.0       2.4
Plastic surgery                1.1       0.7
Thoracic surgery               0.8       0.8
Urology                        2.6       2.7
Hospital-based specialties     --        --
Anesthesiology                 7.0       8.0
Emergency medicine             2.7       4.4
Pathology                      4.1       4.3
Psychiatry                     7.2       9.9
Radiology                      8.0       5.1
Total                        144.0     167.1

Note: In Models D & E, some estimates were made when insufficient
detailed information was available

--Sources: Graduate Medical Education Advisory Committee. Report of the
Graduate Medical Education National Advisory Committee to the
Secretary, Department of Health and Human Services, Vol.1. Washington,
D.C.: Office of Graduate Medical Education, Health Resources
Administration, Public Health Service, U.S. Department of Health and
Human Services, 1980; Weiner, J.P. Forecasting the Effects of Health
Reform on U.S. Physician Workforce Requirement. Evidence from HMO
Staffing Patterns." Journal of the American Medical Association
272(3):222-230; and Goodman, D.C. et al. "Benchmarking the U.
Physician Workforce. An Alternative to Needs-Based or Demand-Based
Planning." Journal of the American Medical Association 276(22):
1811-1817, December 11, 1996; and, Bedford Health Associates, Inc.,
February 1997.

TABLE 2 Abbreviated summary of major findings of a community hospital

   Department/        Current     Quantitative      Personal
     section         full-time    data              Interviews

Anesthesiology           4        No significant    Sufficient
                                  comments          available

Emergency                6        Average           Replacement
medicine                          age is 54.6       with emergency

Allergy/                 2        Low hospital      Medium priority
Immunology                        utilization;      for Immunologist
                                  ages range from
                                  38 to 48

Cardiology               9        Average age is    Surrounded with
                                  43.8; hospital    major defini-
                                  utilization       tional questions
                                  less in 1982
                                  than 1981

Dermatology              3        Minimal           Sufficient
                                  hospital utili-   available

Endocrinology            1        Hospital utili-   Medium priority
                                  zation            for second-
                                  increasing        opinion and less
                                                    complex cases

Gastroenterology         3        Hospital          Sufficient
                                  utilization       available
                                  ages range from
                                  37 to 44

Hematology/              1        Second most       High priority -
Oncology                          active practi-    one active
                                  tioner on staff   physician must
                                                    be added

Infectious               1        Has active        Sufficient
Disease                           practice at       available
                                  age 35

Internal Medicine/       23       12 of 23 FTEs     Need additional
General                           are 50 or         internists on
                                  older, five of    outskirts of
                                  23 FTEs are 62    hospital's
                                  or older;         current services
                                  hospital          area; sufficient
                                  utilization       available
                                  decreasing        elsewhere

   Department/       "Need"   Comments
     section         value    from

Anesthesiology         .125        --

Emergency              .180        --

Allergy/                097        --
Immunology             .311

Cardiology            -.706   Need

Dermatology            .070        --

Endocrinology          .239   Need for

Gastroenterology      -.040        --

Hematology/            .405   Need for
Oncology               .630   second

Infectious             .072        --

Internal Medicine/     .000   Need for
General                       more primary

   Department/       Physician-to-       Recommended
     section         population ratio    FTEs

Anesthesiology       Two additional      4

Emergency            Not applicable      6
medicine             because based
                     on emergency
                     department volume

Allergy/             Two adequate        2

Cardiology           Surplus based       9 *
                     on current

Dermatology          Surplus of one      3

Endocrinology        One adequate        1

Gastroenterology     Adequate number     3

Hematology/          Three required      2

Infectious           Adequate number     1

Internal Medicine/   Need for more       26
General              general

* These FTE cardiologists are sufficient, any excess cardiologists
could be added to 26 general internists required,for a total of 32

--Bedford Health Associates, Inc.


(1.) Weil, T.P. "Do More Physicians Generate More Hospital Utilization hospital utilization The usage rate of a particular health care facility; a group of statistics referring to a population's use of hospital services ?" Hospitals 55(23):70-74, February 1982.

(2.) Miller, R.H., and, Luft, H.S. "Managed Care Plan Performance since 1980: A Literature Analysis." Journal of the American Medical Association JAMA: The Journal of the American Medical Association is an international peer-reviewed general medical journal, published 48 times per year by the American Medical Association. JAMA is the most widely circulated medical journal in the world.  271(19):1512-1519, May 18, 1994

(3.) Seifer, S.D., Troupin, B., and Rubenfeld, G.D. "Changes in Marketplace Demand for Physicians." Journal of the American Medical Association 276(9):695-699, September 4, 1996.

(4.) Weiner, J. "Forecasting the Effects of Health Reform on U.S. Physician Requirements: Evidence from HMO Staffing Patterns." Journal of the American Medical Association 273(3):222-230, July 20, 1994.

(5.) Simon, C.J., and Born, P.H. "Physician Earnings in a Changing Managed Care Environment." Health Affairs 15(3):124-133, Fall 1996.

(6.) Graduate Medical Education National Advisory Committee (GMENAC). "Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS
." Vol. 1. Washington, D.C.: Office of Graduate Medical Education, Health Resources Administration, Public Health Services, U.S. Department of Health and Human Services, 1980.

(7.) Goodman Goodman was a polite term of address, used where Mister (Mr.) would be used today. Compare Goodwife.

Goodman refers to:

  • goodwife, Mississippi, USA
  • Goodman, Missouri, USA
  • Goodman, Wisconsin, USA
, D.C., Fisher, E.S., Bubolz, T.A., Mohr, J.E., Poage, J.F., and Wennberg, J.E. "Benchmarking the U.S. Physician Workforce. An Alternative to Needs-Based or Demand-Based Planning." Journal of the American Medical Association 276(22): 1811-1817, December 11, 1996.

(8.) Wennberg, J.E., Goodman, D.C., Nease, R.F., and Keller, R.B. "Finding Equilibrium in U.S. Physician Supply." Health Affairs 12(3):89-103, Fall 1993.

(9.) Politzer, R.M., Gamleil, S.R., Cultice, J.M., Bazell, C.M., Rivo, M.L., and Mullan, F. "Matching Physician Supply and Requirements: Testing Policy Recommendations. Inquiry 33(3):181-194, Summer 1996.

(10.) Schroeder, S.A. "How Can We Tell Whether There are too Many or too Few Physicians? The Case for Benchmarking. Journal of the American Medical Association 276(22):1841, December 11, 1996.

(11.) Mulhasuen, R., and McGee, J. "Physician Need: An Alternative Projection from a Study of Large Prepaid Group Practices prepaid group practice,
n See closed panel.
." Journal of the American Medical Association 261(13):1930-1934, April 7, 1989.

(12.) Kronick, R., Goodman, D., Wennberg, J., and Wagner, E. "The Marketplace in Health Care Reform. The Demographic Limitations of Managed Competition." New England Journal of Medicine The New England Journal of Medicine (New Engl J Med or NEJM) is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society. It is one of the most popular and widely-read peer-reviewed general medical journals in the world.  328(2):148-152, January 14, 1993.

(13.) Tarlov, A. "HMO Enrollment and Physicians: The Third Component." Health Affairs 5(1):23-35, Spring 1986.

(14.) Dial, T.H., Palsbo, S.E., Bergsten, C., Gabel, J., and Weiner, J. "Clinical Staffing in Staff- and Group-Model HMOs." Health Affairs 14(2):168-180, Summer 1995.

(15.) Weiner, op cit Op Cit Opere Citato (Latin: In the Work Mentioned) , Table 2, p. 224.

(16.) Hart, L.G., Wagner, E., Pirzado, S., Nelson, A.F., and Rosenblatt, R.A. "Physician Staffing Ratios in Staff-Model HMOs: A Cautionary Tale A cautionary tale is a traditional story told in folklore, to warn its hearer of a danger.

There are three essential parts to a cautionary tale, though they can be introduced in a large variety of ways.
." Health Affairs 16(1):55-70, January/February 1997.

(17.) Weil, T.P., and Brenner, G. "Physician and Other Ambulatory Care Services in Germany." Journal of Ambulatory Care Management 20(1):77-91, January 1997.

(18.) Institute of Medicine. The Nation's Physician Workforce Options for Balancing Supply and Requirements. Washington, D.C.: National Academy Press, 1996.

(19.) Gamliel, S., Politzer, R.M., Rivo, M.L., and Mullan, F. "Managed Care on the March: Will Physicians Meet the Challenge?" Health Affairs 15(1):131-142, Spring 1996.

(20.) Pew PEW. A seat in a church separated from all others, with a convenient space to stand therein.
     2. It is an incorporeal interest in the real property. And, although a man has the exclusive right to it, yet, it seems, he cannot maintain trespass against a person
 Health Professions Commission. "Critical Challenges Revitalizing re·vi·tal·ize  
tr.v. re·vi·tal·ized, re·vi·tal·iz·ing, re·vi·tal·iz·es
To impart new life or vigor to: plans to revitalize inner-city neighborhoods; tried to revitalize a flagging economy.
 the Health Professions for the Twenty-first Century." Third Report. San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden : Pew Health Professions Commission, 1995.

(21.) Council on Graduate Medical Education. "COGME COGME Council on Graduate Medical Education  1995 Physician Workforce Funding Recommendations for Department of Health and Human Services Programs." Seventh Report. Rockville, Maryland Rockville is the county seat of Montgomery County, Maryland, United States. According to the 2006 census update, the city had a total population of 59,114, making it the second largest city in Maryland. : HRSA HRSA Health Resources & Services Administration (US)
HRSA Historical Radio Society of Australia
HRSA Hamilton Rating Scale for Anxiety
HRSA Hotel and Restaurant Suppliers Association (Canada) 
, 1995.

Thomas P. Weil, PhD, is President of Bedford Health Associates, Inc., Management Consultants for Health and Hospital Services, in Asheville, North Carolina Not to be confused with Ashville.

Asheville is a city in Buncombe County, North Carolina, and is its county seat. As of the 2000 census, the city had a total population of 68,889. It is the largest city in western North Carolina, and continues to grow.
. He can be reached at 704/252-1616 or via fax at 704/253-3820.
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:Medicinae Doctor
Author:Weil, Thomas P.
Publication:Physician Executive
Geographic Code:1USA
Date:May 1, 1997
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