Chair’s Report

Through a glass, darkly: The difficulties of predicting current and future Emergency Physician supply and demand.

“For now, we see through a glass, darkly; but then face to face: now I know in part; but then shall I know even as also I am known.” From 1 Corinthians 13:12. Attributed to Saul of Tarsus (commonly known as Saint Paul): King James Version (KJV).

We are the Emergency Medicine Workforce Section and logically we are interested in the current deployment as well as the future forecast of the emergency medicine workforce.

The Association of American Medical Colleges (AAMC) has an annual update of physician supply and demand. In the 2019 update¹ emergency medicine is lumped under “Other specialties” category. The “Other Specialties category consists of anesthesiology, emergency medicine, neurology, pathology, physical medicine and rehabilitation, psychiatry, radiology, and all other specialties. Emergency medicine is playing a vital and an increasingly complex role in the health care delivery of this nation that it warrants specific and more precise scrutiny and own figures.

As a starting point the report’s modelling algorithm assumes the extremely debatable 2013 Truven study that 71% of emergency department (ED)visits made by patients with employer-sponsored insurance coverage were avoidable and could be shunted elsewhere for treatment².  The model predicts an 18% decline in ED visits, relative to the status quo demand projections, with a corresponding decrease in demand for emergency physicians. A more definitive study by Hsia and Niedzwiecki found out that only 3.3% of ED visits are avoidable³. This study agrees with the Centers for Disease Control and Prevention (CDC) finding that only 4.3% of ED visits were for nonurgent medical symptoms in 2016; down from 5.5% in 2015⁴.

 A cohort study of data from a large commercial health plan from 2008 to 2015 by Poon, et al. established that ED visits per enrollee for the treatment of low-acuity conditions decreased by 36%, while utilization of non–ED acute care venues increased by 140%⁵. CDC data for the most recent year available continues to show a rising trend of ED visits; with 145.6 million patients in 2016 compared to more than 136.9 million visits for 2015.

The AAMC model projection also predicts that the rapid growth in supply of advanced practice providers (APPs) will partially offset the projected growing shortfall of physicians. Currently there appears to be a mismatch in staffing urban, rural, and suburban ED populations. Are APPs utilized the same way everywhere or are their scope of practice geographically determined? What kind of supervision do they need, and by whom, and can they ever replace or be equivalent to residency trained board-certified physicians? Is the current training of APPs suitable for the emergency workforce and can that training be standardized?

Some EPs are transitioning into “non-traditional” work settings. How many of them are there and what are those settings? What is their impact to the emergency workforce now and in the future? How about the role of tele-health in emergency medicine? How can that impact the workforce dynamic? Could tele-health be leveraged in areas with physician maldistribution? How many non-residency trained EPs and non-ACEP-affiliated EPs are currently practicing emergency medicine and in what locations?

Forecasting the future workforce demand in emergency medicine is necessary but is becoming harder to do. Your workforce leadership has been trying to answer some of these questions. Our Board Liaison, Dr. Kivela, is a very perceptive fellow and when you talk to him it is obvious that he has been thinking a lot about some of these issues and has a clear vision of what the needed workforce “big data” should look like. He feels the big picture is determining how to prepare current residents for the work environment that will exist today and 30 years from now in the dramatically changing world of EM. 

That is the challenge for ACEP leadership.

References

1. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf (Accessed May 19, 2019)
2. https://truvenhealth.com/media-room/press-releases/detail/prid/113/study-finds-most-emergency-room-visits-made-by-privately-insured-patients-avoidable (Accessed May 19, 2019)
3. Hsia RY, Niedzwiecki M, Avoidable emergency department visits: a starting point,International Journal for Quality in Health Care, Volume 29, Issue 5, October 2017, Pages 642–645, https://doi.org/10.1093/intqhc/mzx081 (Accessed May 19, 2019)
4. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf (Accessed May 19, 2019)
5. Poon SJ, Schuur JD, Mehrotra A. Trends in Visits to Acute Care Venues for Treatment of Low-Acuity Conditions in the United States From 2008 to 2015. JAMA Intern Med. 2018;178(10):1342–1349.

Leslie Mukau MD FACEP