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Footnotes

1. The Lewin Group and Altarum updated the PSM and PRM under contract HRSA-230-BHPr-27(2).
2. The PRM has evolved over time from a model to forecast requirements for primary care physicians to a model to forecast requirements for numerous medical specialties. The PRM was formerly known as the Integrated Requirements Model (IRM).
3. The education, training, credentialing, and licensing of allopathic medical doctors (MDs)  and doctors of osteopathic medicine (DOs) is similar. The main difference between the two degrees is the DO emphasis on the musculoskeletal system and how an injury or illness in one area can affect another.
4. The PSM was designed primarily as a national model and thus does not track physicians by geographic location within the United States.  The physician workforce is, however, unevenly distributed throughout the Nation, with pockets of severe shortages (primarily in poor, rural and inner-city areas).
5. The AMA defines “active” as working 20 or more hours per week in professional activities. The estimates provided in this paper include only physicians under age 75.
6. Physicians whose medical specialty and patient care/non-patient care classification is listed as unknown were distributed across specialties and patient care classification based on each specialty’s/classification’s share of total active physicians.
7. IMGs are defined as graduates from accredited medical schools outside the United States, Canada, and Puerto Rico. Canadians, Puerto Ricans, and citizens of U.S. territories are not subject to the visa policies that affect the ability of foreign IMGs to practice in the U.S.
8. Statistics obtained through personal correspondence with James Hallock, Educational Commission for Foreign Medical Graduates.
9. The prevalent belief over the past decade that the United States has an oversupply of physicians (especially specialists) that would grow more severe over time led to over numerous calls for policies that restrict the number of new physicians and the generalist/specialist mix of new physicians. Recommendations included: (1) a moratorium on the creation of new medical schools, (2) limiting total enrollment in U.S. medical schools, (3) limiting the number of residency slots to 110 percent of the number of graduates from U.S. medical schools, (4) trying to achieve a 50/50 balance of generalists and specialists, and (5) changing funding for GME to encourage more training in primary care specialties.
10. Many employers of physicians measure the productivity of individual physicians in terms of the revenue they generate (e.g., using resource-based relative value scale units, or RVUs).
11. At the time this analysis was conducted, the 1999 survey was the most recent SMS data publicly available. Based on conversations with AMA, however, it was decided to use the 1998 survey because the response rate was higher and the sample size was larger.
12. Separation rates calculated for use in the PSM differ by physician age, sex, and USMG or IMG. The PSM does not have different separation rates by medical specialty, although the Career Change Module in the PSM is used to “retire” physicians at earlier ages for high-intensity specialties such as emergency medicine.
13. Although the AMA remains the most accurate source of information on the physician workforce, the process whereby AMA currently surveys one third of its members every 4 years means that up to a 4-year lag could exist between when a physician’s activity status changes and when that change is recorded in the AMA Masterfile. Furthermore, activity status is self reported, and some retired physicians might fail to respond to the AMA survey. Recognizing this problem, the AMA automatically recodes as retired all physicians age 75 and older who fail to respond to its survey and all physicians who receive AMA retirement benefits.
14. Estimates of physician retirement rates were obtained via personal correspondence with Bob Konrad, principal investigator for the PWS.
15. The Congressional Budget Office (CBO) projects a 3 percent annual growth rate in real Gross Domestic Product (GDP) between 2003 to 2013, which is approximately equal to about 2 percent average annual growth in real per capita GDP. Real economic growth, controlling for changing demographics, occurs through an increase in productivity. CBO projections, therefore, assume that worker productivity will increase by approximately 2 percent annually, on average, throughout the economy. For modeling purposes,  an annual 1percent growth in physician productivity is assumed, which will likely increase less rapidly than overall productivity due to the labor intensiveness of physician services.
16. A survey of 835 physicians by Hojat et al. (2000) found that 59 percent agreed with the statement that “cost should be considered an important factor by physicians in their decisions concerning the care of their patients.”
17. The eight categories are ages 0–4, 5–17, 18–24, 25–44, 45–64, 65–74, 75–84, and 85 and older.
18. As with the physician supply estimate, this count uses AMA and AOA Masterfile data on physicians’ activity status for physicians younger than age 75.
19. The entire population age 65 and older is assumed insured under Medicare.
20. These index values are based on an analysis of health care utilization patterns using 1999 to 2001 data from the NAMCS, NHAMCS, NIS, NNHS and NHHS (see BHPr, 2003).
21. Macro-level measures of ability to pay include gross domestic product (GDP) per capita and personal income per capita. An example of a micro-level measure of ability to pay is average household income.
22. Holahan and Pohl (2002) find, however, that changes in per capita GDP in the United States during the period 1994 to 2000 results in little change in the overall number of insured persons. While downturns in economic activity result in a decline in number of persons insured under private plans, economic downturns result in an increased number of households eligible for Medicaid. The analysis does not, however, indicate whether the quality of the insurance products changes with changes in per capita GDP.
23. Note that this graph excludes Luxembourg, a small OECD country with the highest per capita GDP ($46,960 in U.S. dollars) and one of the lowest percentages of GDP spent on health care (6 percent). The simple correlation of per capita GDP and the percent of GDP spent on health care produces a correlation coefficient of 0.75 when Luxembourg is omitted, and a coefficient of 0.52 when Luxembourg is included.
24. Again, Luxembourg is omitted as an extreme outlier. Slovakia is omitted because data on physicians per capita is unavailable.
25. Specialties hypothesized to be in this low-sensitivity category include general and family practice, general internal medicine, pediatrics, obstetrics/gynecology, and emergency medicine.
26. Specialties hypothesized to be in this medium-sensitivity category include cardiology, internal medicine subspecialties, general surgery, otolaryngology, urology, anesthesiology, radiology, pathology, and “other” specialties.
27. Specialties hypothesized to be in this high-sensitivity category include orthopedic surgery, ophthalmology, “other” surgery, and psychiatry.
28. The assumption that all NPCs that are trained will become employed thus reducing demand for physicians is a strong assumption. The National Health Service Corps (NHSC), which helps to place primary care physicians and NPCs in underserved areas, has reduced the number of new NPCs participating in the program because of recent difficulties in placing NPCs at NHSC-qualified sites despite strong demand for additional physicians at these sites.
29. Over the past 20 years, the percentage of total Federal and nonFederal physicians engaged primarily in non-patient care activities has steadily declined from around 9 percent to its current level of about percent.
30. In the HMO example, market forces provide a strong incentive for the HMO to have a sufficient number of physicians and an appropriate specialty mix to ensure patient access to quality care. Access to care and quality of services are vital to recruiting and retaining HMO enrollees. Market forces (i.e., the profit motive) provide a strong incentive to contain costs by eliminating unnecessary services and by supplying physician services using the most cost-effective mix of health workers (e.g., using a mix of specialist physicians, primary care physicians, NPCs and other health workers).