Special Article| Volume 40, ISSUE 6, P899-911, December 01, 2010

# Estimate of Current Hospice and Palliative Medicine Physician Workforce Shortage

• Author Footnotes
a Members of the AAHPM Workforce Task Force: Chair: Loren Friedman, MD; Members: Jeffrey Alderman, MD, DO, Rachelle Bernacki, MD, Lindy Landzaat, DO, Susan McHugh-Salera, NP, Christopher Pile, MD, Andrew Putnam, MD, Michelle Weckmann, MD, and Deidra Woods, MD.
Open Access

## Abstract

### Context

In the context of the establishment of a new medical specialty, rapid growth in hospices and palliative care programs, and many anecdotal reports about long delays in filling open positions for hospice and palliative medicine (HPM) physicians, the American Academy of Hospice and Palliative Medicine (AAHPM) appointed a Workforce Task Force in 2008 to assess whether a physician shortage existed and to develop an estimate of the optimal number of HPM physicians needed.

### Objectives

Develop estimates of the current supply and current need for HPM physicians. Determine whether a shortage exists and estimate size of shortage in full-time equivalents (FTEs) and individual physicians needed.

### Methods

The Task Force projected national demand for physicians in hospice- and in hospital-based palliative care by modeling hypothetical national demand on the observed pattern of physician use at selected exemplar institutions. The model was based on assumptions that all hospices and hospitals would provide an appropriate medical staffing level, which may not currently be the case.

### Results

Approximately 4400 physicians are currently HPM physicians, as defined by board certification or membership in the AAHPM. Most practice HPM part time, leading to an estimated physician workforce level from 1700 FTEs to 3300 FTEs. An estimated 4487 hospice and 10,810 palliative care physician FTEs are needed to staff the current number of hospice- and hospital-based palliative care programs at appropriate levels. The estimated gap between the current supply and the hypothetical demand to reach mature physician staffing levels is thus 2787 FTEs to 7510 FTEs, which is equivalent to 6000–18,000 individual physicians, depending on what proportion of time each physician devotes to HPM practice.

### Conclusion

An acute shortage of HPM physicians exists. The current capacity of fellowship programs is insufficient to fill the shortage. Changes in graduate medical education funding and structures are needed to foster the capacity to train sufficient numbers of HPM physicians.

## Introduction

The National Priorities Partnership has highlighted palliative and end-of-life care as one of six national health priorities that have the potential to create lasting change across the health care system.
• National Priorities Partnership
A growing evidence base has demonstrated the potential of palliative care to control costs, improve quality, and enhance patient and family satisfaction for a rapidly expanding population of patients with serious and life-threatening illness.
Improving efficiency in end-of-life care also increases quality of life. By providing patient-centered palliative care, patients may receive more of the services they want and less of what they do not want, thus decreasing health care costs and increasing quality. However, delivery of high-quality hospice and palliative care cannot take place without sufficient number of health professionals with appropriate training and skills.
The rapid expansion of hospice and palliative care programs over the past two to three decades has taken place within a general context of concern about looming nursing and physician shortages. Although there is debate about the optimal size of the physician workforce, most agree there is a maldistribution of physicians between primary care and subspecialties, leading to shortages in specific disciplines.
• Kirch D.G.
• Vernon D.J.
Confronting the complexity of the physician workforce equation.
Even while questioning the need for expanding the physician specialist workforce overall, Goodman and Fisher
• Goodman D.C.
• Fisher E.S.
Physician workforce crisis? Wrong diagnosis, wrong prescription.
advocate “reallocating current medical education funding toward programs (such as primary care residencies and geriatric and palliative care fellowships) that could lead to improved care coordination and chronic-disease management.”
The American Academy of Hospice and Palliative Medicine (AAHPM) received numerous anecdotal reports about long delays and difficulties in filling open positions for hospice and palliative medicine (HPM) physicians. The AAHPM appointed a Workforce Task Force in 2008, charged with assessing whether a shortage existed and developing an estimate of the number of HPM physicians needed to meet patient care needs. This article reports the methods and findings of the Task Force’s work in developing a projection for the number of HPM physicians needed.
There were 3389 Medicare-certified hospices serving over one million Medicare patients in 2008.

Neuman K. Assessing payment adequacy: hospice. Presentation at MedPAC meeting, January 14, 2010, Washington, DC. Available from http://www.medpac.gov/meeting_search.cfm?SelectedDate=2010-01-14%2000:00:00.0. Accessed January 18, 2010.

There are 1299 hospitals with palliative care programs.
However, published information about the number of physicians working in these programs is scarce. A 2002 study described characteristics of the HPM physician workforce at that time but did not project the workforce needed.
• Cohen B.P.
• Salsberg E.
The supply demand and use of palliative care physicians in the United States.
An analysis of the 2006 Medicare Provider of Service database showed that virtually all Medicare-certified hospices have a physician on the team, and that for-profit hospices are more likely to have a paid staff physician rather than a volunteer physician (91.6% paid physician) than nonprofit hospices (79.7%) or government hospices (75.2%).
• Cherlin E.
• Carlson M.
• Herrin J.
• et al.
Interdisciplinary staffing patterns: do for-profit and nonprofit hospices differ?.
The National Hospice and Palliative Care Organization (NHPCO) National Data Set reports that 3.4% of all hospice full-time equivalents (FTEs) were physicians (nonvolunteer).
• National Hospice and Palliative Care Organization
NHPCO facts and figures: Hospice care in America, 2009 ed.
No national data on the prevalence of physicians in hospital-based palliative care are available yet, although the Center to Advance Palliative Care (CAPC) does plan to collect such data and report it in the future.

## Methods

### Supply of HPM Physicians

To estimate the current supply of HPM physicians, this report gathered information from several organizational databases that track membership in or certification by relevant physician membership and/or certifying bodies. Although data from the AMA Masterfile are often used to characterize physician specialty, the data on palliative medicine were deemed unreliable. In 2008, the AMA Masterfile contained only 818 physicians with a specialty listing of palliative medicine, 143 as a primary specialty and 675 as a secondary specialty. However, this is much lower than the number who are board certified in the field and thus not likely to be an accurate representation of the palliative medicine workforce. Therefore, alternative sources of information were used to estimate supply. Membership data were obtained from the AAHPM. The total number of certified physicians was obtained from the American Board of Hospice and Palliative Medicine (ABHPM) (which conducted the certifying exam in the period 1996 through 2006) and from the American Board of Medical Specialties (which conducted the certifying exam in 2008). Data from the certifying exam conducted by the American Osteopathic Association (AOA) boards in 2009 were not included in the estimate because they were not available at the time of the study. Expert opinion was used to estimate the likely overlap between these data sources to arrive at an estimate of the current number of HPM specialists in practice.

### Demand for HPM Physicians

In the absence of an agreed-upon national standard on the appropriate physician staffing level for hospice- or hospital-based palliative care, we chose to make a projection by modeling hypothetical national demand on the observed pattern of physician use at selected exemplar institutions. This is a hypothetical “demand,” rather than an empirically determined economic demand. We based these projections on data from three exemplary hospices (for hospice staffing), data from one academic medical center (for hospital-based palliative care), and the staffing recommendations used by CAPC in its technical assistance to palliative care programs. The rationale was that basing the projection on exemplar institutions as a hypothetical exercise can show the number of physicians that would be needed to enable all hospices and palliative care programs to rise to the level of service provided by the exemplar programs.
We made separate projections for the number of physicians needed to staff hospice programs and the number of physicians needed to staff hospital-based palliative care programs. We did not attempt to estimate the number of physicians needed to provide palliative care in long-term care settings, home-based palliative care (as distinct from hospice care), or ambulatory palliative care clinics, as all of these services are relatively new and their staffing models are still emerging.
Three different methods were used to project estimates of national need for physician FTEs for hospices. Results of the first method, which produced a low, middle, and high estimate, were used as the basis for the workforce projections. The two alternative methods were used to verify the plausibility of the results from the first method. The first method is based on the national number of hospice patient days. The second method is based on the annual number of hospice admissions, and the third method is based on estimates of staffing based on hospice census size. The results of the different methods converged, giving added confidence in the plausibility of the estimates produced by the first method based on patient days.

### Data to build the models estimating need were obtained from the following sources:

• Hospice medical staffing ratio per patient day and per admission was taken from three hospices judged by the Workforce Task Force to have “exemplary” physician service models. These hospices contributed annual operating and staffing data sufficient to calculate physician FTEs per patient day and per admission.
• Conversion of individual physicians to FTEs was based on reported hours worked per week in Cohen and Salsberg
• Cohen B.P.
• Salsberg E.
The supply demand and use of palliative care physicians in the United States.
and previously unpublished data from an AAHPM survey of members, reported in Table 1.
Table 1Calculation of FTE per Physician from AAHPM Data
Business Practices AAHPM Member Survey
On average, how many hours per week do you spend in the practice of Hospice and Palliative Medicine? (include all activities in HPM including clinical, teaching, research, and administrative duties)
Hours per WeekResponse Percent (%)Response CountHours per Week Assumed for CalculationTotal Person HoursCalculated FTE
50+ hours32.2120404,800
40–49 hours15.859402,360
30–39 hours11.844351,540
20–29 hours13.149251,225
10–19 hours13.14915735
5–9 hours10.53910390
Fewer than 5 hours3.513452
Answered question37311,102277.55
• National hospice patient days and admissions were calculated from Medicare hospice data for fiscal year (FY) 2008 and NHPCO data on proportion of all hospice patients that are paid by Medicare.
• Physician staffing ratio for hospital-based palliative care was developed from CAPC recommendations.
• Total staffed hospital beds were obtained from American Hospital Association data.

### Hospice Estimates

#### Hospice Estimate Method 1: Projection Based on National Patient Days

In the absence of any agreed-upon standard for the appropriate physician staffing level for a hospice, we chose to use an approach that builds on the experience of exemplary hospices with mature medical staffing models. The three exemplar hospices have robust programs that provide a full range of hospice care across multiple settings, including both home hospice and inpatient hospice. Using these hospices’ experience, we projected the number of physicians that would be needed to enable all hospices to rise to this exemplary level of service delivery. These estimates should not be taken to be a prescription for a particular staffing model or staffing level and should not be used as benchmarks for an individual hospice’s productivity or staffing level.
Table 2 describes the hospice characteristics and the standard policy for physician care. The hospices range in size from an average daily census of 300 to over 1400. All of the hospices have a robust set of services, including hospice home care and freestanding hospice inpatient units. All three of these hospices also use nurse practitioners and/or physician assistants as part of their medical staff (Table 3).
Table 2Description of Medical Staffing Model for Three Exemplary Hospices
Hospice Characteristics and Staffing ModelHospice 1Hospice 2Hospice 3
Average daily census14731057312
Number of hospice inpatient beds staffed by hospice staff physicians487124
Percentage of patient days by level of care (%)
Routine home care93.993.389.5
Continuous care1.72.30.3
Respite care0.100.1
General inpatient care4.34.410.1
Medical staffing model
For patients managed by hospice medical staff
• Initial visit within 10 days of admission.
• Follow-up visit every 60 days for noncancer patients, every 30 days for cancer patients or if patient has a medical problem that needs to be addressed.
Staff sees on admission and every 10 days or as needed.Staff sees within seven days of admission and every five to six weeks for routine follow-up or more often if needed (about 15% of total home census).
Home patients—consultative role only
• See within two weeks of admission and then at recertification periods.
• See any medically stable patient being considered for discharge.
If no management role, then monthly visits.For home patients seen in consultation (at request of attending MD), seen within two days, with follow-up as indicated.
InpatientIn own inpatient facilities, patients seen daily, seven days per weekInpatient unit patients seen six to seven days per week.Acute level inpatients are seen six days per week.
Table 3Staffing Information for Three Exemplary Hospices
Medical StaffHospice 1Hospice 2Hospice 3
Physician FTE11.210.54.25
NP FTE7.561
PA FTE020
Total medical staff FTE18.718.55.25
Total admissions571449542286
Total patient days540,047385,87677,717
NP=nurse practitioner; PA=physician assistant.
The information on medical staffing models at the three exemplary hospices was used to calculate the observed ratio of physician and medical staff FTEs to patient days and to total admissions. The observed ratios are shown in Table 4. The observed ratio of physician FTEs to patient days was then applied to national information about the total number of hospice patient days in FY 2008, estimated to be 86,170,239 patient days. This estimate of total patient days was arrived at by taking the reported total Medicare patient days in FY08 (74,968,108 patient days)
• Centers for Medicare & Medicaid Services
US Department of Health & Human Services. Table V.14: Hospice-Medicare national summary.
and increasing it by a factor to account for the additional non-Medicare patient days. According to the NHPCO, Medicare accounts for 87% of patient days.
• National Hospice and Palliative Care Organization
NHPCO facts and figures: Hospice care in America, 2009 ed.
Table 4Observed Ratio of Physicians and Total Medical Staff to Patient Days
Patient Days per Medical Staff FTEHospice 1Hospice 2Hospice 3
Patient days/physician FTE48,21836,75018,286
Patient days/NP FTE72,00664,31377,717
Patient days/PA FTE0192,9380
Patient days/medical staff FTE28,88020,85814,803
NP=nurse practitioner; PA=physician assistant.
To arrive at the national estimates, the total national number of patient days was divided by the observed ratio of physician FTEs to patient days. This yields a calculation of needed physician FTEs nationally to replicate the staffing model of the particular exemplar hospice. The calculation for Hospice 1 is given as an example below:
$86,170,239pt days48,218pt days/MD FTE=1787MD FTE nationally$

#### Hospice Estimate Method 2: Alternative Method Based on Admissions

An alternative estimate was made using annual admissions rather than patient days. According to NHPCO data, the total US hospice admissions, less carryover patients (assuming carryover at end of year equals carryover at beginning of year), during 2008 was 1,142,000 patients.
• National Quality Forum
A national framework and preferred practices for palliative and hospice care quality.
Using data from the three hospices, projected annual need for FTEs was then calculated as follows (using Hospice 1 as an example):
$1,142,000admissions510admissions/physician FTE=2238physician FTE$

#### Hospice Estimate Method 3: Alternative Method Based on Staffing Model by Hospice Census Size

An alternative calculation was performed using assumptions about the number of physician FTEs needed based on the size of hospice programs (measured in annual admissions). The numbers of current hospices of each program size were calculated from percentages of the total number of hospices given by the NHPCO for 2008.
• National Hospice and Palliative Care Organization
NHPCO facts and figures: Hospice care in America, 2009 ed.
An estimate of the amount of physician FTEs needed for a hospice in each size range was made using expert opinion. The estimates were conservative and assumed that many small hospices would use part-time physicians. Estimated FTEs ranged from 0.1 FTE for a hospice admitting less than 50 patients annually (18.5% of US hospices) to 4.0 FTEs for hospices admitting more than 1500 patients annually.

### Palliative Care Estimates

We applied the overall CAPC recommendation to develop the low and middle estimates for the number of palliative care physician FTEs needed if palliative care had complete penetration across the country. To produce the high estimate, we used data from one large academic medical center that has used a more generous staffing level than the CAPC recommendation for start-up programs.
CAPC recommends a staffing ratio of one physician FTE for every 250–350 staffed beds (personal communication, May 27, 2009). This level of physician staffing assumes a full interdisciplinary team, including advanced practice nurses who supplement and extend the physician staffing. The data from the academic medical center showed the use of one physician FTE per 155 hospital beds, with an additional physician assistant for every MD.
For the low estimate, we assumed the lower range of the CAPC recommendation (one FTE per 350 staffed beds). The middle estimate applies the higher range of CAPC's recommended staffing level (one physician per 250 staffed beds) to all US hospital beds. For the high estimate, we assumed better physician staffing of one physician per 155 beds, as seen in the academic medical center whose data we reviewed.

### Conversion of FTEs to Number of Physicians

Because most HPM physicians practice HPM part time, it is necessary to estimate the FTE level produced by a given number of physician individuals using a conversion factor. We used two sources of survey data to estimate the conversion factor between FTEs and total number of physicians. As shown below, these data sources produced an estimate of current FTEs per physician, ranging from 0.48 to 0.75 FTE per practicing physician. However, because the respondents to these two surveys are likely those spending a greater proportion of their time in HPM, we used a slightly lower factor (0.4 FTE) when estimating the low end of the currently available supply of HPM physicians.
The first estimate was based on data from a 2002 study conducted for the Health Resources and Services Administration (HRSA).
• Cohen B.P.
• Salsberg E.
The supply demand and use of palliative care physicians in the United States.
This study collected data from 1271 physicians who were either members of the AAHPM or certified by the ABHPM. We assumed that each physician worked at the high end of the range of hours given as a response to the survey. We then calculated the total number of hours all survey respondents worked. This resulted in a calculation that the 1271 responding physicians worked an overall total of 24,324 hours per week (Table 5, Column 4). Dividing by an average of 40 hours per week for one FTE results in the total number of FTEs, shown in Column 5. Finally, dividing the 608 FTEs in Column 5 by the 1271 total respondents gives an average of 0.48 FTE per respondent. This means each responding physician devoted about half of his or her time to HPM, on average (0.48 FTE per physician).
$608.11total FTE1271total physicians=0.4779FTE per physician$

Table 5Calculation of FTEs per Individual Physician with Data from Cohen and Salsberg
n=1271Column 1Column 2Column 3Column 4Column 5
Hours Worked per Week in HPMPercentage of Respondents
From Cohen BP, Salsberg E. The supply, demand, and use of palliative care physicians in the United States. Rensselaer NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany, 2002.
Calculated Number of Respondents Based on Column 1 and Overall n=1271Hour Assumption for Each CategoryTotal Hours Calculated by Multiplying Column 2 by Column 3Column 4 Total Divided by 40 Hours per FTE Results in Calculation of Total FTEs
0–953.2%676.17296085.548
10–1921%266.91195071.29
20+25.9%329.1894013167.56
Total100%1272.27124324.398608.10995
a From Cohen BP, Salsberg E. The supply, demand, and use of palliative care physicians in the United States. Rensselaer NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany, 2002.
An unpublished 2008 survey of AAHPM members collected data on the weekly hours members devoted to HPM. Summing across all 373 respondents showed that they worked a total of 11,102 hours, which comes out to 0.75 FTE per physician (Table 1).
$277.5total FTE373total physicians=0.744FTE per physician$

## Results

### Supply

We estimate that at the end of 2009, there were approximately 4400 physicians spending some part of their professional time practicing HPM (Table 6). However, most of these physicians practice HPM part time. Assuming that current HPM physicians spend, on average, 40%–75% of their time on HPM, the current available FTE level ranges from 1700 FTEs to 3300 FTEs.
Table 6Estimate of Total Current Supply of HPM Physicians
Data SourceGross NumberAssumptionEstimated ReductionNet Number
AAHPM current members (2009)2926No reduction02926
AMA masterfile818Assume all contained in another group8180
ABHPM board certified2883Assume 10% attrition due to retirement or career change; assume 60% are current AAHPM members18451038
ABMS board certified1266Assume 2/3 newly certified were already AAHPM members or ABHPM certified836430
Total physicians789334994394 physicians
Estimated FTEsAssume 0.4–0.75 FTE per physician1700–3300 FTEs

### Demand—Hospice Setting

Table 7 summarizes the results of the three methods used to model hypothetical demand for HPM physicians. Because the range resulting from Method 1 encompassed the results of the other methods, Method 1 results were used as the basis for the final projections.
Table 7Summary of Hospice Physician FTE Need Estimates Produced by Different Calculation Methods
Hospice Physician FTEs NeededLowMediumHigh
Method 1—based on patient days178723454712
Method 2—based on annual admissions212322382420
Method 3—based on Average Daily Census (ADC) of hospicen/an/a4272

#### Hospice Demand—Method 1

Table 8 displays the physician FTEs needed using Method 1, which ranged from 1713 physician FTEs to 4516 physician FTEs. Note that these estimates for the number of physician FTEs were predicated on physician practice within the context of an interdisciplinary team and additional medical staff, such as nurse practitioners and/or physician assistants. Total medical staff FTEs ranged from 2859 to 5578.
Table 8Medical Staff FTEs Needed Based on Method 1—National Hospice Patient Days
Calculation of Medical StaffHospice 1Hospice 2Hospice 3
National number of patient days
Data for Medicare patient days, FY08, from Centers for Medicare & Medicaid Services, US Department of Health & Human Services. Data Compendium: 2009 Edition.9
Data for percentage of patient days under Medicare from National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America.8
86,170,23986,170,23986,170,239
Calculated MD FTEs needed178723454712
Calculated NP FTEs needed119713401109
Calculated PA FTEs needed447
Calculated total medical staff FTEs needed298441315821
MD=physician; FTE=full-time equivalent; NP=nurse practitioner; PA=physician assistant.
a Data for Medicare patient days, FY08, from Centers for Medicare & Medicaid Services, US Department of Health & Human Services. Data Compendium: 2009 Edition.
• Centers for Medicare & Medicaid Services
US Department of Health & Human Services. Table V.14: Hospice-Medicare national summary.
b Data for percentage of patient days under Medicare from National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America.
• National Hospice and Palliative Care Organization
NHPCO facts and figures: Hospice care in America, 2009 ed.

#### Hospice Demand—Method 2

Calculations of physician FTEs needed using Method 2, based on admissions, show a much narrower range than the results of Method 1. Method 2 projects a need ranging from 2124 physician FTEs to 2420 physician FTEs (Table 9). Total medical staff FTEs (including physicians as physician extenders and advanced practice nurses) ranged from 2623 to 4265.
Table 9Medical Staff FTEs Needed Based on Method 2—National Hospice Admissions
Calculation of Medical StaffHospice 1Hospice 2Hospice 3
National number of hospice admissions1,142,0001,142,0001,142,000
Calculated MD FTEs needed223824202123
Calculated NP FTEs needed14991383500
Calculated PA FTEs needed461
Calculated total medical staff FTEs needed373742652623
MD=physician; FTE=full-time equivalent; NP=nurse practitioner; PA=physician assistant.

#### Hospice Demand—Method 3

An alternative calculation was performed using assumptions about the number of physician FTEs needed based on the size of hospice programs (measured in annual admissions). This method provided an estimate that 4272 FTE physicians are needed to staff the current number of hospices at their current size (Table 10).
Table 10Physician FTEs Needed Based on Method 3—Hospice Census
Admissions per Hospice
National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America.8
Distribution of 2700 Hospices
National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America.8
Estimated FTE Physicians per HospiceCalculated Total FTE Physicians
1–4918.50%8700.187
50–15028.00%13160.25263
151–50032.90%15460.51546
501–1,50016.10%7561.51512
More than 15004.60%2164.0864
4272
a National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America.
• National Hospice and Palliative Care Organization
NHPCO facts and figures: Hospice care in America, 2009 ed.

### Demand—Hospital-Based Palliative Care

Projections for the number of physician FTEs needed to staff hospital-based palliative care programs ranged from 2701 FTEs to 6098 (Table 11).
Table 11Physician FTEs Needed for Hospital-Based Palliative Care
Low Palliative Care EstimateMiddle Palliative Care EstimateHigh Palliative Care Estimate
Total staffed beds in all US-registered hospitals
American Hospital Association. Fast Facts on US Hospitals. Available from http://www.aha.org/aha/resource-center/Statistics-and-Studies/fast-facts.html. Accessed May 27, 2009.
945,199945,199945,199
Physician FTE per staffed bed ratio1 FTE/350 beds1 FTE/250 beds1 FTE/155 beds
Physician FTEs needed270137816098
a American Hospital Association. Fast Facts on US Hospitals. Available from http://www.aha.org/aha/resource-center/Statistics-and-Studies/fast-facts.html. Accessed May 27, 2009.

### Combined Hospice- and Hospital-Based Palliative Care Demand

We estimate that between 4487 and 10,810 physician FTEs are needed to staff the current number of hospice- and hospital-based palliative care programs at appropriate levels (Table 12). Converting FTEs to individual physicians (because most HPM physicians practice HPM part time), this means that between 5983 and 18,017 individual physicians are needed to meet current demand.
Table 12Total FTEs and Individual Physicians Needed
Physician FTEs NeededLowMiddleHigh
Hospice FTEs based on patient days178723454712
Palliative care FTEs based on staffing per hospital bed270037806098
Total FTEs for hospice and palliative care combined4487612510,810
Number of physicians needed at 0.75 FTE per individual5983816714,413
Number of physicians needed at 0.60 FTE per individual747810,20818,017

### Gap Between Supply and Demand

The gap between current supply and estimated current demand (if all hospices and palliative care programs used exemplary staffing models) ranges from 2787 FTEs to 7510 FTEs (Table 13). Between 6000 and 18,000 individual physicians would be needed to meet the gap, assuming that each physician practices HPM at 0.6–0.75 FTE.
Table 13Gap Between Supply and Need for HPM Physicians
Physician Supply GapLowMiddleHigh
Total estimated need in FTEs: hospice and palliative care4487612510,810
Total estimated supply in FTEs17002500
Middle estimate of supply is average of high and low estimates as given in Table 1.
3300
Gap in HPM physician FTEs278736257510
a Middle estimate of supply is average of high and low estimates as given in Table 1.

### Sensitivity of Estimates to FTE Conversion Factor

Currently most physicians work only part time in HPM. As the field matures, we expect that many physicians will increase the proportion of their time devoted to HPM, with more and more becoming full-time HPM physicians. However, the extent to which this will happen and how quickly it will happen is hard to predict. We calculated a sensitivity analysis to show the impact that the FTE conversion factor had on the estimate of the total number of physicians needed (Table 14). If physicians work, on average, half time (0.5 FTE), the middle estimate for number of individual physicians needed is 12,250. However, if physicians devote more of their professional time to their HPM role, the number of individual physicians needed declines to 6804, at 0.9 FTE per physician.
Table 14Effect of FTE Conversion Factor on Estimate of Number of Physicians Needed
Average FTE Conversion AssumptionTotal FTEs Needed (Middle Estimate)Total Number of MDs Needed to Provide FTE Level
0.25612524,500
0.45612513,611
0.5612512,250
0.6612510,208
0.7561258167
0.861257656
0.961256806

## Discussion

The results of this modeling exercise confirm the anecdotal reports from the field: there is currently a shortage of HPM physicians. In fact, it is likely that the existing supply of practicing HPM physicians is already constraining hospices and palliative care programs, forcing them to use staffing models that fall short of the ideal. For instance, hospital-based palliative care programs with a single physician often struggle to meet the National Quality Forum preferred practice stating that a program should “Provide access to palliative and hospice care that is responsive to the patient and family 24 hours a day, 7 days a week” (10). Similarly, many hospices would like to be able to provide physician home visits, but are unable to do so routinely because of physician staffing limitations.

### Limitations of Model Projections

The major assumption used in this model was that workforce “need” is equivalent, on average across all programs, to the staffing intensity used by the “exemplary” hospices and palliative care services whose staffing data informed the model ratios. To the extent that these exemplary programs are either over- or understaffed compared with the true need of other programs, the need estimates of the model will be inaccurate. However, in the absence of an acknowledged gold standard for medical staffing, it is impossible to gauge “true” need.
The model we used to estimate need was very simple and has some serious limitations. It models only current need, ignoring future population growth and aging. It models only current workforce needs for hospice- and hospital-based palliative care programs, disregarding possible future program expansions, such as increased palliative care in long-term care settings. It uses staffing ratios that are suited to the current regulatory environment, but that may not be adequate under future Medicare regulations, such as those that require a physician visit to recertify a patient’s eligibility for hospice. Finally, this model does not break out the specific workforce needs of particular sectors, such as pediatrics or academia (which requires physicians to be able to carry out teaching and research functions, and clinical care). The workforce needs for pediatrics and for academia are important questions to be addressed in future work.
Major changes in the health care environment influencing how hospice and palliative care services are delivered would impact the model’s staffing projections. Possible changes in the environment that would influence workforce needs are discussed below.

### Factors that would lead to a need for more HPM physicians:

• Expansion in number of hospice inpatient beds, especially at the general inpatient level (GIP), because higher physician staffing is needed per patient for the high acuity level served in hospice GIP beds as compared with the physician staffing for hospice home care or residential patients.
• Further penetration of palliative care into long-term care and growth of home-based palliative care programs beyond current hospice models.
• Medicare regulatory changes requiring more physician involvement in hospice (e.g., new hospice Conditions of Participation in effect as of October 1, 2009 require hospice physicians to write an expanded narrative for all new patients and all recertification of patients, leading to additional physician workload; the recommendation to require physician visit to hospice patient at 180 days also would lead to additional physician workload).

### Factors that would lead to a need for fewer HPM physicians:

• Greater availability of nurse practitioners and other advanced practice nurses with specific skill in palliative medicine could reduce the workload for HPM physicians.
• If HPM physicians devote, on average, a greater proportion of their professional time to HPM (such as working 40 hours per week in HPM rather than 32), fewer individuals will be needed (although the need as measured in FTEs would not necessarily change).

### Implications for Expansion of Training Programs and Innovation in New Training Models

Currently there are 74 HPM fellowship programs, of which 68 are accredited by the Accreditation Council for Graduate Medical Education (ACGME) and three by the AOA.
• American Academy of Hospice and Palliative Medicine
The programs have the capacity to train about 180 HPM physicians annually. Assuming about 1/30th of current physicians will retire annually, this is not enough to keep up with replacement in even the lowest estimate-of-need scenario. Assuming that in the future more of these physicians would work full time in HPM, the annual need for new physicians—just to keep pace—would be about 269 physicians for the middle estimate and about 472 physicians for the high estimate (Table 15). More will be needed to prepare for growth and aging of the population. Training capacity thus needs to expand considerably.
Table 15Estimated Annual Number of HPM Physicians Needed to Replace Those Retiring
AssumptionLowMediumHigh
Retirement replacement need at 1/30th—0.75 FTE assumption199272480
Retirement replacement need at 1/30th—0.60 FTE assumption249340601
The cap on the number of residency positions Medicare will fund makes it especially difficult for a new specialty to take root. Although there is debate as to whether or not the overall supply of physicians needs to be increased or simply reallocated,
• Goodman D.C.
• Stukel T.A.
• Chang C.
• Wennberg J.E.
End-of-life care at academic medical centers: implications for future workforce requirements.
the need for more physicians with skills in HPM is undeniable. Either we retrain existing physicians in the skills of HPM or we bring new physicians into this practice capacity.

### Solutions include the following:

• Ensure graduate medical education (GME) payments for HPM: pay for full FTE (rather than 0.5) for palliative medicine fellowship training programs. This is needed because of workforce shortages in these areas and is similar to existing GME funding provisions for geriatric medicine and pediatric neurology fellowship programs.
• Support extension of GME to allow payments to community-based training programs and sites of service.
• Lift the cap on residency position funding for ACGME-accredited training programs for HPM.
• Advocate for Palliative Care Academic Career Awards and Palliative Care Education Centers through HRSA (similar to Title VII Geriatric Health Professions Training Programs).
GME traditionally has not had the flexibility to adapt to the needs of practicing physicians who may want to shift specialties or practice emphasis. Many physicians only discover their interest in and affinity for HPM midcareer. A rigorous training program that is adaptable to the commitments of practicing physicians may attract additional doctors and help to relieve the shortage of HPM physicians. An educational pathway that invites interested, experienced physicians to engage in additional training is needed as one solution to the shortage.
Providing such a pathway of formal training in a new field also may allow some mature physicians to extend their careers. HPM values the profound knowledge base and holistic perspective derived from years of clinical practice. This appeals to experienced, late-career physicians. By offering training in a fulfilling new area of practice, respected physicians could be enticed to delay their retirement. This would serve as one immediate way to address the predicted upcoming shortage of physicians.

### Implications for Workforce Projections for Other Physician Specialties

As part of the solution to projected physician shortages, other medical disciplines are recommending increasing reliance on HPM physicians and their interdisciplinary teams to assist with the complex, time-consuming, and emotionally taxing care of patients with serious illness. For instance, the American Society of Clinical Oncology predicts a severe shortage of oncologists in coming years and anticipates much more collaboration with other specialties, primary care physicians, and nonphysician providers.
• Shulman L.N.
• Jacobs L.A.
• Greenfield S.
• et al.
Cancer care and cancer survivorship care in the United States: will we be able to care for these patients in the future?.
However, for this strategy to succeed, there must be a sufficient supply of HPM physicians available. Thus, closing the gap between the supply and the demand for HPM physicians should be a concern not just to the hospice and palliative care field but to all health professionals who care for patients with serious and complex illness.

## Disclosures and Acknowledgments

Institutional support for this project was provided by the AAHPM . Members of the AAHPM Workforce Task Force provided essential guidance, key information, oversight, and support throughout this project. Special thanks to the three hospices and one palliative care program that provided data but did not wish to be named to protect the confidentiality of the organizational identities.

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