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HRSA's Workforce Report Confirms Intensivist Shortage
References
View HRSA report
The Health Resources and Services Administration (HRSA) released its critical care workforce report in May 2006, reinforcing growing concerns about the shortage of intensivists. This new information surfaces even as the shortage is expected to worsen with the aging of the U.S. population, and the Society of Critical Care Medicine (SCCM) is working with its partners in the critical care community to ensure a viable and healthy workforce for the future.
Society president Charles Durbin Jr., MD, FCCM, represented the Society during a May 23 press conference in San Diego, California, USA, held by the Critical Care Workforce Partnership. The Society has partnered with the American Thoracic Society, the American College of Chest Physicians and the American Association of Critical-Care Nurses to form the Critical Care Workforce Partnership, a coalition dedicated to developing solutions to the possible healthcare crisis brought on by this shortage. After unveiling this report, the Partnership outlined several goals and formal responses, and Dr. Durbin’s presence reinforced the Society’s commitment to addressing the shortage aggressively on a variety of fronts.
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IOM: Emergency Care in a Critical State
The Institutes of Medicine (IOM) in June 2006 released three reports on the state of emergency medicine in the United States. Though the focus of these reports lies outside critical care, the late Peter Safar, MD, FCCM, reminded us that critical care is a continuum beginning with pre-hospital care, extending through interventions in the emergency department and leading to management services in the intensive care unit. (ICU). The conditions described by the IOM are relevant to Society of Critical Care Medicine members and their patients.
Emergency Physicians
According to recent utilization data, over a five-year period, the Centers for Medicare and Medicaid Services (CMS) accepted more than two times as many Medicare claims for initial critical care services from emergency physicians (EPs) (18.5%) than from critical care physicians
(6.8%). Critical care services are provided frequently in the emergency department (ED), so circumstances affecting the ED are likely to have implications for the critically ill and injured.
Emergency Department Overcrowding
The IOM reports reiterate a by-now familiar problem in the ED – the departments are overcrowded, leading to ambulance diversions and delays in providing services. At one time, these conditions were temporary. Today, it is common for EDs to “board” patients in the ED, often on gurneys or hospital beds parked in hallways, when proper inpatient beds (including ICU beds) are not available. Boarding of critically ill patients is, in part, a result of the ICU bed shortage, which is one manifestation of the workforce shortage.
Underserved Areas
Hospitals in underserved areas of the country have difficulty obtaining the resources necessary to obtain critical care specialists when faced with huge demands for general services. Resources will be stretched thinner as demand for ED services increases.
Summaries of the IOM reports as well as additional resources are available online. | “The HRSA report puts a new focus on the physician shortage and gives the Society and its partners new allies in solving this problem,” Dr. Durbin said. “While the HRSA report focuses entirely on physician shortages, we must remember that other members of the ICU team also are in short supply, including nurses, respiratory therapists, clinical pharmacists and others. The Society has supported legislation to improve recruitment for these essential clinicians for many years and will continue these efforts for all members of the multiprofessional team.”
The shortage of intensivists has been one of the Society’s top priorities in its mission to improve care for the critically ill and injured. The Society believes it is important to focus efforts in appropriate areas to help relieve the shortage and to spread accurate information about the progress being made.
In 2000, SCCM contributed to the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS) report, which projected a growing shortfall of critical care physicians unless changes were made to increase the number of trainees entering the workforce. In June 2006, Critical Care Medicine published an editorial by Shorr, et al. titled “Do intensive care unit patients have intensive care unit physicians? Unfortunately not,” which updated the report.1 Most recently, the June 2006 issue of Critical Connections featured an article providing updated data from the Accreditation Council for Graduate Medical Education (ACGME) on the number of critical care physi¬cian trainees entering the workforce. The article analyzed data showing that the number of professionals entering the workforce was strong, but recognized that the reasons for the shortage are varied and complicated. The HRSA report reminds us that this issue has many angles and facets that must be thoroughly investigated.
The latest data from HRSA strengthens the Society’s efforts as it continues to work with other societies, legisla¬tors and those within the healthcare community to combat the critical care workforce shortage and ensure the best possible care for patients. The report, which was conducted at the request of the Critical Care Workforce Partnership, is significant because it amounts to independent confirmation of the Partnership’s own analysis, effectively giving the Partnership another ally in its mission. It also updates the Partnership analysis with independent data gathered since the publication of COMPACCS in 2001.
The Facts Facing the Critical Care Workforce
The HRSA report, The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians, found that as hospitals continue to staff their intensive care units (ICUs) with critical care physicians, and as the U.S. popula¬tion ages, demand will likely outpace supply. Evidence sug¬gests that the “closed ICU model,” which assigns an inten¬sivist or team of intensivists to the ICU on a full-time basis, is linked to improved patient outcomes. The “closed ICU model” may save more than $5 billion and 53,000 lives in non-rural U.S. hospitals, and more hospitals are seeking to add these healthcare professionals to their staff.
Even more pressing is the aging U.S. population. Americans older than age 65 consume the majority of ICU services. By 2020, the population aged 65 and older will increase by 50% and by 100% in 2030. Currently, about one-third of patients receive care from an intensivist. As the popularity of the “closed ICU model” increases, HRSA recommends the benchmark that two- thirds of ICU patients should be managed by a team directed by an intensivist in order to receive the best care possible. However, that goal presents a very real supply and demand problem. According to HRSA’s data, the current workforce is made up of about 2,000 full-time intensivists, and it is expected to increase to about 2,800 by 2020. That number falls well short of the approximately 4,300 full-time intensivists needed to staff the country’s ICUs by that time (as defined by HRSA’s benchmark). Also, because intensivists are more likely to provide care in larger hospitals, the shortage likely will affect areas that already have limited access to physicians.
It is important to note that HRSA only collected data for full-time intensivists. The Society estimates that nearly 8,100 critical care physicians practice in the United States -- a number that includes physicians providing critical care services full- or part-time. The COMPACCS study used survey data from physicians trained in pulmonology, critical care or both specialties to determine the number of physicians practicing in an ICU and the average hours per week spent providing critical care services. HRSA’s data relies on the American Medical Association (AMA) Masterfile to estimate the cur¬rent intensivist supply, but that database did not allow HRSA to determine which pulmonologists provide critical care in an ICU, and so were omitted from consideration.
The growing demand is complicated further by the number of critical care professionals entering the workforce. HRSA’s conclusions about the supply of the critical care workforce fall in line with data from COMPACCS. Again, considerable differences exist between HRSA’s projections and COMPACCS' projections of supply and demand for critical care physicians, partly because of the different definitions for an “intensivist” and “critical care physician.” HRSA breaks down the number of intensivists according to specialty, gender, age and how much time they spend in the ICU.
Review the Data
HRSA found that the number of physicians self-designated as practicing “pulmonary/critical care medicine” nearly doubled in the four-year period from 1998 to 2001. This may reflect a shift in training programs from pulmonary medicine alone to combined pulmonary and critical care programs as well as a change in self-designation choices. However, self-designated specialty does not reveal how physicians are actually spending their clinical time. On average, 94% of pulmonologists and critical care physi¬cians were engaged primarily in direct-patient care in 2000. Critical care pulmonary physicians were the most likely to be engaged in patient care (98%) compared with those who considered themselves pulmonary specialists alone (88%).
The report found that men still make up 68% of pulmonologists and critical care physicians, though the number of women is growing. The highest proportion of women were trained in critical care pulmonology (23%) and critical care anesthesiology (19%). Most men were trained in critical care pulmonology (90%) and critical care medicine (83%).
The majority of critical care pulmonary physicians are between ages 35 and 44, which reflects the relatively new status of both specialties. Self-designated pulmonologists tend to be older than physicians practicing exclusively in critical care. About 64% of pulmonologists are older than age 45, compared to between 4% and 31% of the physicians for each of the critical care specialties examined. Age is significant when discussing workforce because it is highly correlated with retirement decisions and plays a significant role in hours worked. Physicians older than age 65 tend to work fewer hours than their younger colleagues. According to COMPACCS survey data, more than half of critical care physicians expect to retire by age 60 and almost one-third expect to retire by age 55.
Age, retirement plans, gender and clinical practice, along with other factors, contribute to the projected criti¬cal care physician supply. Part-time intensivists effectively reduce the number of full-time equivalent (FTE) physicians. For example, adding 2,000 physicians who practice as intensivists 50% of the time to a base of 2,000 full-time intensivists would deliver the amount of services associated with 3,000 full-time intensivists. Despite an overall increase in the number of graduates with critical care training in recent years, decreases in the number of hours worked and rising numbers of retirees would lead to a flat number of providers by 2020. This, of course, does not take into account the expected increase in demand.
The Society Is Taking Action
As part of the Critical Care Workforce Partnership, the Society is at the forefront of efforts to boost awareness and catalyze efforts to improve the situation. By dedicat¬ing resources to increasing the critical care workforce, the Society is staying true to its mission to improve patient care in the ICU.
The Partnership is working with Sen. Richard J. Durbin, D-Ill., to draft legislation aimed at developing solutions to the shortage. The group is at the beginning stages of this effort, but ideally legislation would work to:
Increase the supply of critical care providers by:
• Increasing the effective supply of critical care providers through cross-training
• Increasing medical and nursing school capacity to train critical care providers
• Expanding federally funded graduate medical education slots for critical care providers
• Reducing the debt burden of critical care physicians
Increase the efficiency and optimization of critical care services by:
• Conducting research on optimal critical care delivery models
Provide support for research into critical care services and therapies/treatment by:
• Developing incentives to distribute critical care provid¬ers better
Encourage innovations in critical care by:
• Introducing new staffing models and new technologies
• Increasing the use of technology through telemedicine initiatives and electronic medical records
The HRSA report represents a policy victory for the Society, as it independently validates SCCM's position on the workforce. It also signals the beginning of a new phase in advocacy – a time to refresh and reinforce efforts to iden¬tify and promote solutions. The Society will take advantage of the new opportunities developing as the reality of this report reaches those outside the critical care community and will continue to build alliances with those also interested in providing a better overall healthcare experience for the critically ill and injured.
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