Cardiovascular Workforce - The Potential Impact of Healthcare Reform

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Disclosure:This manuscript is based on his October 14, 2009 presentation in The Distinguished Lecturer Series sponsored by the Dayton Heart Institute of the Good Samaritan Hospital.

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The details of healthcare reform are entirely unclear at the time of writing. However, our understanding of the current status of the cardiovascular workforce has never been clearer. In the US, 80 million people have heart disease. The prevalence of this condition increases by 1% per year. Cardiovascular specialists have much to be proud of. There has been a 52% reduction in cardiovascular mortality over the last 25 years and there are now more adult ‘survivors’ with congenital heart disease than there are children. So, the problem in the US is that we have more survival of cardiovascular disease than ever. In addition, there is going to be an annual 3% expansion in the 65–85-year-old age group due to the bulge in the population caused by baby-boomers. Finally, we must deal with the growing epidemic of obesity. Today, over 25% of adults have a body mass index greater than 30. With this epidemic, diabetes and cardiovascular disease are sure to follow.

The current supply of cardiologists actively practicing in the US is as follows: there are approximately 17,000 general cardiologists, 5,000 interventional cardiologists, and 2,000 electrophysiologists for a total of approximately 24,000 cardiologists throughout the US. Unfortunately, only 12% of cardiologists are women and only 6% are represented by minorities (Hispanic and African-American) versus 25% of the general population of the US. There are 179 cardiology fellowship programs that produce approximately 750 new cardiologists every year. Fortunately, there does not appear to be a pipeline problem at present. Every year, 1,200 internal medicine residents compete for these 750 cardiology fellowship slots. Perhaps the most disturbing issue with regard to our current cardiovascular workforce is the fact that 43% of cardiologists are 55 years of age or older. It is during this period of time that physicians may for the first time start to consider retirement. As we have surveyed individuals, we have found that health reasons are the primary reason for earlier retirement—and there is a growing number of spinal problems developing among interventionalists and electrophysiologists. However, second to this is the burden of call, the hassles of regulations, and declining reimbursement.

In 2006 and 2007 we surveyed a large number of private practices and academic practices. We asked them if they were actively recruiting a cardiologist—in other words, did they have an open position for a cardiologist. We felt that employers of cardiologists would be the best estimate of the demand for cardiovascular services since they are intimately in touch with the regions that they serve. We found that overall there were 4,000 open positions, 1,700 of which were general cardiology positions. Over the last two years the American College of Cardiology’s (ACC’s) task force on cardiovascular workforce worked with the Lewin Group and the Association of American Medical Colleges (AAMC) to study this issue of the cardiovascular workforce. Their projections are that we will be short of 16,000 general cardiologists by 2025.

There are five main drivers of demand:

  • Demographics and population: as previously mentioned, there is a bulge in the population due to the baby-boomers. Previously, the growth of the 65–85-year-old age group was 1% per year; once the baby-boomers enter this age group, it will increase to 3% per year.
  • The epidemic of obesity.
  • The expansion of coverage anticipated with healthcare reform. Currently, there are 47 million Americans who either have no insurance or very little insurance and, therefore, little access to cardiovascular specialists. This may change radically with healthcare reform.
  • Economic growth: once there is recovery from the recession, this may intensify demand.
  • Technological advances.

With healthcare reform, there is sure to be an increase in the number of individuals with insurance coverage and, therefore, greater access to cardiovascular specialists. However, the cardiovascular workforce is already short of 4,000 individuals. This will obviously put more stress on the system. The current versions of healthcare reform suggest that there will be an increase in funding for primary care physicians but not necessarily for specialty fellowship positions such as cardiology. There is also concern that healthcare reform will bring with it an increase in government regulation. Some of the proposals that have been put forward have suggested a radiology benefit management (RBM) process whereby cardiovascular specialists will have to obtain approval from the RBM prior to any diagnostic imaging. Finally, there is some concern about a decrease in reimbursement. The ACC has advocated for a change in the way in which physicians are incentivized and paid such that quality and value are rewarded rather than quantity of service. However, the concern that many physicians have is that the government will simply cut all reimbursement.

The doomsday scenario is one in which an increase in government regulation as well as a decrease in reimbursement declines too rapidly for the cardiovascular workforce to adequately adjust. The concern is that this would precipitate an enormous increase in earlier retirement. Remember, 43% of the entire cardiovascular workforce is 55 years of age or older. Could the system sustain a loss of 25% of actively practicing cardiologists? This would amount to a loss of 6,000 cardiologists within the space of a few years, when the input of cardiologists is 750 per year. There is already a deficit of 4,000. The concern is that this would be devastating to the delivery of cardiovascular care.

The ACC certainly advocates gradual change so that the cardiovascular workforce can adjust. Payment reforms should incentivize quality and value rather than quantity of services. Government regulations should be reduced and meaningful tort reform enacted to further decrease the overhead expense of high medical malpractice premiums. The ACC further advocates an increase in cardiology fellowship positions and incentives such that we can develop a much more diversified cardiovascular workforce. Finally, the college is actively involved in promoting best practices in the team care delivery of cardiovascular care that involve greater utilization of non-physician practitioners such as nurse practitioners and physician assistants.