Recent media coverage has focused on the supply of physicians in the United States, especially with the impact of a growing physician shortage and the Affordable Care Act. State medical boards and other entities maintain data on physician licensure and discipline, as well as some biographical data describing their physician populations. However, there are gaps of workforce information in these sources. The Federation of State Medical Boards' (FSMB) Census of Licensed Physicians and the AMA Masterfile, for example, offer valuable information, but they provide a limited picture of the physician workforce. Furthermore, they are unable to shed light on some of the nuances in physician availability, such as how much time physicians spend providing direct patient care. In response to these gaps, policymakers and regulators have in recent years discussed the creation of a physician minimum data set (MDS), which would be gathered periodically and would provide key physician workforce information. While proponents of an MDS believe it would provide benefits to a variety of stakeholders, an effort has not been attempted to determine whether state medical boards think it is important to collect physician workforce data and if they currently collect workforce information from licensed physicians. To learn more, the FSMB sent surveys to the executive directors at state medical boards to determine their perceptions of collecting workforce data and current practices regarding their collection of such data. The purpose of this article is to convey results from this effort. Survey findings indicate that the vast majority of boards view physician workforce information as valuable in the determination of health care needs within their state, and that various boards are already collecting some data elements. Analysis of the data confirms the potential benefits of a physician minimum data set (MDS) and why state medical boards are in a unique position to collect MDS information from physicians.
For decades, the question of predicted physician numbers and demographics and its influence on the availability of medical care has been a top concern for policy makers in the field of medicine.1 Information about physicians and where they practice is again becoming relevant, as the Affordable Care Act is expected to bring increased numbers of previously uninsured patients into the market place for medical care. Even before the planned implementation of this historic reform, there were concerns that the demand for care in the United States had exceeded the supply of physicians. One estimate claims a shortage of 130,000 physicians by 2025.2
Data from the American Medical Association's (AMA) Physician Masterfile is a widely used source for information about physicians in the United States. The Association of American Medical Colleges (AAMC) uses the AMA Masterfile to produce a biennial report examining physician supply, medical school enrollment, and graduate medical education in the United States.3 While researchers have used the AMA Masterfile to study topics such as migration trends for surgeons4 and the emergency physician workforce,5 others have noted the AMA Masterfile sometimes lags in identifying and updating changes to physician records, such as a change in a physician's specialty, retirement or licensure status.6 Some claim this lag results in an overestimation of the number of active physicians in the older age range.7,8,9,10
For example, Douglas Staiger and his colleagues used the AMA Masterfile and data from the U.S. Census Bureau's Current Population Survey (CPS) to conduct parallel retrospective cohort analyses of trends in the number of active physicians, and found that compared to CPS data, the AMA Masterfile showed fewer young physicians entering the work-force and more active older physicians remaining in the workforce.9
In recent years, the Federation of State Medical Boards (FSMB) addressed the physician workforce topic by undertaking a census of licensed physicians every two years.11 Each census made important contributions to the health workforce conversation by providing an accurate assessment of the number of actively licensed physicians in the United States. Though valuable, sources such as the FSMB's census of licensed physicians and the AMA Masterfile provide a limited picture of the physician workforce and are unable to shed light on some of the nuances in physician availability. To address this lack of specific physician workforce data, the FSMB established a workgroup to explore the possibility of creating a minimum data set (MDS). The workgroup concluded that a minimum data set could improve upon previous efforts by collecting standardized physician data at the time of licensure renewal.12 It also agreed that an MDS could provide accurate and consistent information about physicians to state and federal policy makers which could then be used in planning and resource allocation.
Methods of Survey
Although an MDS may provide benefits to various stakeholders, no effort has been made to determine systematically whether state medical boards think it is important to collect physician workforce data and whether they currently collect workforce information from licensed physicians. The FSMB designed a survey instrument to gauge state boards' views on the importance of collecting physician workforce information, how state boards currently collect this information, the types of data they collect, and the challenges they may face with implementing a minimum data set of questions. The FSMB emailed a link to complete the online survey to the executive directors of the 69 physician-licensing boards in the United States and its territories. The only state medical board that did not receive the survey was the New York State Board for Professional Medical Conduct, which deals with physician discipline, not licensure. No incentives to complete the survey were offered, and data were collected between February and March of 2013. There appears to be no systemic bias in the boards that agreed to participate in the survey. IBM® SPSS statistical analysis software was used to compute frequencies and cross-tabulations to convey responding boards' perceptions of collecting workforce information and the demographic information they collect from physicians.
Individuals from 55 of the 69 licensing boards completed the survey (80% response rate), representing a broad cross-section of the state medical boards in the United States. Of the 55 responding boards, 28 are smaller boards (licensing less than 10,000 physicians), 16 medium-sized (10,000 to 30,000), and 11 larger boards (more than 30,000). The majority of the respondents to the survey were state board executive directors (82%). Nearly all state boards permit physicians to renew their licenses online, with only four state boards in the sample requiring a paper renewal. Among boards that allow physicians to choose between online or paper renewal, a majority (26 of 38) reported that at least 80% of their physicians renew their licenses online, suggesting that online renewal is by far the most prevalent method of license renewal (Table 1).
An overwhelming majority of respondents believe it is important to collect physician workforce data, as 82% of boards claimed that collecting workforce data is “extremely important” or “important”.* Only 4% of respondents claimed that it is “somewhat important” to collect physician data (Figure 1). The importance of collecting workforce data on physicians is also represented by state medical boards' current practices on collecting physician data. Of the 55 responding boards, 36 (66%) indicated they currently collect workforce information from their licensed physicians (Figure 2). Furthermore, 33 of the 36 boards (92%) that collect workforce data indicate that they do so during the license renewal process.
As indicated in Figure 3, the data that state medical boards who responded to the survey are most likely to require from physicians at the time of license renewal include year of graduation from medical school (80%), age (78%), and medical school (73%).
Other information, such as gender, area of practice, practice location, and employment status, was collected nearly as frequently but was much less likely to be required.
Practice setting (44%) and specialty board certification (51%) are fairly likely to be collected by boards, but items such as these are more likely to be voluntary than required (Figure 4). Other items such as race, ethnicity, and languages spoken are less likely to be collected, and are overwhelmingly voluntary when they are collected by state boards.
State boards indicated they are aware of the FSMB's efforts to begin establishing a minimum data set (71%), and most expressed interest in working with the FSMB on this initiative (82%). Some boards, however, identified challenges such as reluctance from licensees (28%), information technology and software issues (18%), political concerns (16%), and human and financial resources (13%).
Discussion and Conclusion
Understanding the physician workforce is increasingly important, considering the gradual but undeniable shift in the demographic composition of the aging population in the United States. The baby boomer generation began turning 65 in 2010, and it is estimated that each day an additional 10,000 baby boomers will reach the age of 65.13 This is especially important because Americans who are older than 65 years are overrepresented among the number of visits to the doctor's office,14 suggesting that there will be an increased demand for health care as the baby boomer generation continues to age. Not only is the demand for health-care increasing, but concerns about the sustainability, cost, and delivery of health care underscore the importance of understanding the physician work-force.15 The findings from our survey indicate that the vast majority of state medical boards view physician workforce information as valuable in their determination of health care needs, and various boards are already collecting some data elements of an MDS.
Though the AMA Masterfile provides aggregate information about physicians, records in the file are created when individuals first enter medical school or, in the case of International Medical Graduates (IMGs), when they first enter the country. Physician records are updated by use of a rotating census where approximately one fourth of all physicians are surveyed each year.16 A state board's license renewal process provides a unique opportunity for collecting additional, up-to-date workforce information from all licensed physicians in the United States. Twenty-six percent of state boards require physicians to renew their licenses every year, 66 percent require renewal once every two years and the remaining boards require renewal every three years or more.17
The FSMB's MDS workgroup made suggestions to simplify and streamline the process of implementing an MDS. They recommended a core set of questions describing which physicians are providing direct patient care, the types of care these physicians provide, the practice setting in which the care is provided and the areas of the country the care is provided. They proposed that the questions should take less than 10 minutes to complete and should not include data that may be available from other sources, such as FSMB, ABMS or state board databases. The workgroup also suggested that state boards include MDS as part of the renewal process and when possible require physicians to answer questions to boost overall response. Lastly, the group recommended that the FSMB maintain a confidential database to house the information collected for a minimum data set and assist state boards with analysis of the data.
A framework for an MDS has been established, most state boards agree that collecting physician workforce information is important and many are interested in participating in the FSMB's MDS initiative. Much work remains, however, and some state boards identified various challenges associated with full implementation. Existing state policies and statutes and the availability of information technology resources needed to modify existing renewal applications may constrain some boards from participating.
The FSMB is working with boards to facilitate their participation. With support from a supplemental grant through the Licensure Portability Program, the FSMB, in conjunction with the National Center for Health Workforce Analysis of the U.S. Department of Health and Human Services' Health Resources and Services Administration (HRSA), is launching a pilot project to implement a state-based MDS in the United States. The FSMB has indicated that it is ready to assist state boards and is reaching out to its membership to encourage participation and provide help. A comprehensive physician minimum data set would significantly enhance the workforce information currently collected by providing better insight into the amount of time physicians spend providing direct patient care as well as the time they spend in other areas (i.e., administration and teaching). It would also give state boards an opportunity to compare workforce characteristics for their physician population to the nation's total physician population. Finally, it would offer greater insight to state and federal policymakers, managed care organizations, health-care providers and the public as coordinated efforts are made to deliver quality health care across the country in the years ahead.