The Critical Care Workforce:  A Study of the Supply and Demand for Critical Care Physicians

Chapter 5: Summary and Implications

Adequacy of Critical Care Physician Supply: Implications for Vulnerable Populations

The PSM and PDM are national models that yield estimates for the U.S.  population as a whole. Although they can be adapted to project supply and demand for smaller geographic regions such as States, the models do little to inform the debate regarding the future adequacy of physician supply in currently underserved areas.  Past government policies to improve physician supply in underserved areas have relied in part on the assumption that physician surpluses (especially surpluses of primary care physicians) will create financial motivations for physicians to gravitate to underserved areas.  The projections presented here suggest that the supply of physicians will not outpace demand through 2020, which will create little financial pressure for physicians to disperse to traditionally underserved areas.  The regional differences in total per capita physician supply remain striking, as is demonstrated in Exhibit 16, with geographic differences even greater at the sub-region level.

Exhibit 16. Regional Variation in Active Physicians per 100,000 Population [D]

Any shortage of health care providers is likely to be worse in areas (or for populations) that already have limited access to physicians.  This concern is particularly true for access to specialists in rural areas where population size may not support specialties that rely on a large patient referral base and other members of an interdisciplinary team to deliver effective care.

In their analysis, Angus and colleagues found that intensivists were more likely to provide care in larger hospitals (greater than 300 beds), ^[49] which are less likely to be present in rural areas. This disparity may be further reinforced by the pressure from payers to improve ICU staffing in urban hospitals ahead of non-urban locations.  As a previous Department of Health and Human Services report explained, “the challenge lies in understanding what these kinds of quality standards mean for rural communities and whether they are relevant.  While the Leapfrog Group initially focused on urban measures, the group has recently devoted attention to consideration of patient safety standards for rural hospitals, realizing that their focus needed to be system-wide.” ^[50]   However, current mechanisms of physician redistribution might be examined for opportunities to improve access to optimal patient care for underserved patients in the ICU. ^[51]

Areas for Future Research

Several questions about the critical care workforce remain difficult to answer.  In particular, it is unclear how care directed by intensivists leads to improved patient outcomes. ^[52]  Those related specifically to critical care training might be achievable with other health care providers, such as hospitalists, or through improved nurse staffing and the availability of other specialists.  Other organizational characteristics may play a significant role, such as information technology infrastructure in closed unit ICUs.  Further information about critical care providers and their training are also of interest, including the distinction between pulmonologists and intensivists and how these two inter-related specialties will evolve. 

In summary, we project that if current trends continue, the growing supply of intensivists will be insufficient to provide the optimal level of care to future populations through 2020.  A lower bound of projected demand assumes that all growth in demand for intensivist services is due to the growth and aging of the population but the recent growth in intensivist involvement in ICU care suggests that this lower estimate is highly unlikely.  Total employment opportunities will likely grow faster than this lower bound as hospitals increasingly staff their ICUs with intensivists.  An upper bound on the demand projections would occur if intensivists direct the care of two-thirds of patients admitted to the ICU.  The likely demand for intensivists will likely lie somewhere between this upper and lower bound, suggesting the need to increase intensivist supply and to continue monitoring trends in supply and demand.