Abstract
Context
Objectives
Methods
Results
Conclusion
Key Words
Introduction
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.
Methods
Supply of HPM Physicians
Demand for HPM Physicians
Data 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of individual physicians to FTEs was based on reported hours worked per week in Cohen and Salsberg6and previously unpublished data from an AAHPM survey of members, reported in Table 1.Table 1Calculation of FTE per Physician from AAHPM Data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 Week Response Percent (%) Response Count Hours per Week Assumed for Calculation Total Person Hours Calculated FTE 50+ hours 32.2 120 40 4,800 40–49 hours 15.8 59 40 2,360 30–39 hours 11.8 44 35 1,540 20–29 hours 13.1 49 25 1,225 10–19 hours 13.1 49 15 735 5–9 hours 10.5 39 10 390 Fewer than 5 hours 3.5 13 4 52 Answered question 373 11,102 277.55 - •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.
Data to build the models estimating need were obtained from the following sources:
Hospice Estimates
Hospice Estimate Method 1: Projection Based on National Patient Days
Hospice Characteristics and Staffing Model | Hospice 1 | Hospice 2 | Hospice 3 |
---|---|---|---|
Average daily census | 1473 | 1057 | 312 |
Number of hospice inpatient beds staffed by hospice staff physicians | 48 | 71 | 24 |
Percentage of patient days by level of care (%) | |||
Routine home care | 93.9 | 93.3 | 89.5 |
Continuous care | 1.7 | 2.3 | 0.3 |
Respite care | 0.1 | 0 | 0.1 |
General inpatient care | 4.3 | 4.4 | 10.1 |
Medical staffing model | |||
For patients managed by hospice medical staff |
| 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 |
| 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. |
Inpatient | In own inpatient facilities, patients seen daily, seven days per week | Inpatient unit patients seen six to seven days per week. | Acute level inpatients are seen six days per week. |
Medical Staff | Hospice 1 | Hospice 2 | Hospice 3 |
---|---|---|---|
Physician FTE | 11.2 | 10.5 | 4.25 |
NP FTE | 7.5 | 6 | 1 |
PA FTE | 0 | 2 | 0 |
Total medical staff FTE | 18.7 | 18.5 | 5.25 |
Total admissions | 5714 | 4954 | 2286 |
Total patient days | 540,047 | 385,876 | 77,717 |
Patient Days per Medical Staff FTE | Hospice 1 | Hospice 2 | Hospice 3 |
---|---|---|---|
Patient days/physician FTE | 48,218 | 36,750 | 18,286 |
Patient days/NP FTE | 72,006 | 64,313 | 77,717 |
Patient days/PA FTE | 0 | 192,938 | 0 |
Patient days/medical staff FTE | 28,880 | 20,858 | 14,803 |
Hospice Estimate Method 2: Alternative Method Based on Admissions
Hospice Estimate Method 3: Alternative Method Based on Staffing Model by Hospice Census Size
Palliative Care Estimates
Conversion of FTEs to Number of Physicians
n=1271 | Column 1 | Column 2 | Column 3 | Column 4 | Column 5 |
---|---|---|---|---|---|
Hours Worked per Week in HPM | Percentage of Respondents | Calculated Number of Respondents Based on Column 1 and Overall n=1271 | Hour Assumption for Each Category | Total Hours Calculated by Multiplying Column 2 by Column 3 | Column 4 Total Divided by 40 Hours per FTE Results in Calculation of Total FTEs |
0–9 | 53.2% | 676.172 | 9 | 6085.548 | |
10–19 | 21% | 266.91 | 19 | 5071.29 | |
20+ | 25.9% | 329.189 | 40 | 13167.56 | |
Total | 100% | 1272.271 | 24324.398 | 608.10995 |
Results
Supply
Data Source | Gross Number | Assumption | Estimated Reduction | Net Number |
---|---|---|---|---|
AAHPM current members (2009) | 2926 | No reduction | 0 | 2926 |
AMA masterfile | 818 | Assume all contained in another group | 818 | 0 |
ABHPM board certified | 2883 | Assume 10% attrition due to retirement or career change; assume 60% are current AAHPM members | 1845 | 1038 |
ABMS board certified | 1266 | Assume 2/3 newly certified were already AAHPM members or ABHPM certified | 836 | 430 |
Total physicians | 7893 | 3499 | 4394 physicians | |
Estimated FTEs | Assume 0.4–0.75 FTE per physician | 1700–3300 FTEs |
Demand—Hospice Setting
Hospice Physician FTEs Needed | Low | Medium | High |
---|---|---|---|
Method 1—based on patient days | 1787 | 2345 | 4712 |
Method 2—based on annual admissions | 2123 | 2238 | 2420 |
Method 3—based on Average Daily Census (ADC) of hospice | n/a | n/a | 4272 |
Hospice Demand—Method 1
Calculation of Medical Staff | Hospice 1 | Hospice 2 | Hospice 3 |
---|---|---|---|
National number of patient days | 86,170,239 | 86,170,239 | 86,170,239 |
Calculated MD FTEs needed | 1787 | 2345 | 4712 |
Calculated NP FTEs needed | 1197 | 1340 | 1109 |
Calculated PA FTEs needed | — | 447 | — |
Calculated total medical staff FTEs needed | 2984 | 4131 | 5821 |
Hospice Demand—Method 2
Calculation of Medical Staff | Hospice 1 | Hospice 2 | Hospice 3 |
---|---|---|---|
National number of hospice admissions | 1,142,000 | 1,142,000 | 1,142,000 |
Calculated MD FTEs needed | 2238 | 2420 | 2123 |
Calculated NP FTEs needed | 1499 | 1383 | 500 |
Calculated PA FTEs needed | 461 | ||
Calculated total medical staff FTEs needed | 3737 | 4265 | 2623 |
Hospice Demand—Method 3
Admissions per Hospice | Distribution of 2700 Hospices | Estimated FTE Physicians per Hospice | Calculated Total FTE Physicians | |
---|---|---|---|---|
1–49 | 18.50% | 870 | 0.1 | 87 |
50–150 | 28.00% | 1316 | 0.25 | 263 |
151–500 | 32.90% | 1546 | 0.5 | 1546 |
501–1,500 | 16.10% | 756 | 1.5 | 1512 |
More than 1500 | 4.60% | 216 | 4.0 | 864 |
4272 |
Demand—Hospital-Based Palliative Care
Low Palliative Care Estimate | Middle Palliative Care Estimate | High Palliative Care Estimate | |
---|---|---|---|
Total staffed beds in all US-registered hospitals | 945,199 | 945,199 | 945,199 |
Physician FTE per staffed bed ratio | 1 FTE/350 beds | 1 FTE/250 beds | 1 FTE/155 beds |
Physician FTEs needed | 2701 | 3781 | 6098 |
Combined Hospice- and Hospital-Based Palliative Care Demand
Physician FTEs Needed | Low | Middle | High |
---|---|---|---|
Hospice FTEs based on patient days | 1787 | 2345 | 4712 |
Palliative care FTEs based on staffing per hospital bed | 2700 | 3780 | 6098 |
Total FTEs for hospice and palliative care combined | 4487 | 6125 | 10,810 |
Number of physicians needed at 0.75 FTE per individual | 5983 | 8167 | 14,413 |
Number of physicians needed at 0.60 FTE per individual | 7478 | 10,208 | 18,017 |
Gap Between Supply and Demand
Physician Supply Gap | Low | Middle | High |
---|---|---|---|
Total estimated need in FTEs: hospice and palliative care | 4487 | 6125 | 10,810 |
Total estimated supply in FTEs | 1700 | 2500 | 3300 |
Gap in HPM physician FTEs | 2787 | 3625 | 7510 |
Sensitivity of Estimates to FTE Conversion Factor
Average FTE Conversion Assumption | Total FTEs Needed (Middle Estimate) | Total Number of MDs Needed to Provide FTE Level |
---|---|---|
0.25 | 6125 | 24,500 |
0.45 | 6125 | 13,611 |
0.5 | 6125 | 12,250 |
0.6 | 6125 | 10,208 |
0.75 | 6125 | 8167 |
0.8 | 6125 | 7656 |
0.9 | 6125 | 6806 |
Discussion
Limitations of Model Projections
- •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 more 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).
Factors that would lead to a need for fewer HPM physicians:
Implications for Expansion of Training Programs and Innovation in New Training Models
Assumption | Low | Medium | High |
---|---|---|---|
Retirement replacement need at 1/30th—0.75 FTE assumption | 199 | 272 | 480 |
Retirement replacement need at 1/30th—0.60 FTE assumption | 249 | 340 | 601 |
- •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).
Solutions include the following:
Implications for Workforce Projections for Other Physician Specialties
Disclosures and Acknowledgments
References
- Priorities.(Available from) (Accessed July 13, 2009)
- Meier D.E. Isaacs S.L. Hughes R.G. Palliative care: Transforming the care of serious illness. 1st ed. Jossey-Bass, San Francisco2010
- Confronting the complexity of the physician workforce equation.JAMA. 2008; 299: 2680-2682
- Physician workforce crisis? Wrong diagnosis, wrong prescription.N Engl J Med. 2008; 358: 1658-1661
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- The supply demand and use of palliative care physicians in the United States.Center for Health Workforce Studies, School of Public Health, SUNY Albany, Rensselaer, NY2002
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