April 1998 Bulletin

RAND study finds surplus orthopaedists now, 2010

Even sharp training cuts require years for an impact

The long-awaited RAND study, "Estimating Orthopaedic Provider Supply and Demand," concludes there is a surplus of orthopaedic surgeons today and that current training levels will create an even larger surplus in 2010.

The study is not likely to end the quest for a definitive answer of whether there will be a surplus of orthopaedic surgeons in the years ahead as the population ages. Nor does it provide a simple solution like reducing the number of orthopaedic surgeons trained.

Commissioned by the Academy in December 1995 and published in The Journal of Bone and Joint Surgery (JBJS) last month, the study looks at the supply side and the demand side of the issue. In the supply model, RAND found that if the current number of orthopaedic residents - 602 - continue to be trained, the number of orthopaedic surgeons will increase through 2020. To keep the total number of orthopaedic surgeons constant, i.e., at todayís level, about 485 orthopaedic residents need to complete training annually; thatís a 19 percent decline.

It would take more than 10 years before even a 50 percent reduction in training will have a noticeable effect on either the numbers of orthopaedic surgeons or work force ratios of orthopaedic surgeons to 100,000 population.

Although continuing the current training levels will increase overall supply, the ratio of orthopaedic surgeons to population will be at 7.9 per 100,000 by 2010, which is above the staffing ratios used today by a selected number of managed care organizations. A 50 percent reduction in training would reduce the ratio to 6.2 which is still above all but one of the managed care ratios used for comparison.

RAND also developed "demand-based" estimates using utilization rates for the treatment of musculoskeletal diseases and population changes. RAND converted the number of orthopaedic surgeons into full-time equivalents (FTE). RAND assumed an individual orthopaedic surgeon spent 2,200 hours in direct patient care. Combining demand with a current supply of 18,296 FTEs, results in a current surplus of 3,546 FTEs. Projecting supply and demand estimates to 2010 indicates the surplus will increase 16.2 percent to 4,122 FTEs.

If demand would remain the same and orthopaedic surgeons would reduce their work an average of 19 percent, the surplus would disappear. If orthopaedic surgeons were to become the preferred physician for more conditions and procedures, then demand for orthopaedists would grow accordingly.

Reducing the training by 50 percent would eliminate the surplus FTEs and produce a small deficit. However, the elimination of the surplus comes only if the training levels are decreased

RAND recognized the limitations of both methods. The ratio method implies a large surplus and indicates, perhaps, a drastic reduction in training, the researchers said. The demand modeling suggests much less of a surplus and smaller reductions. Unforeseen circumstances could produce a shortage, they said, warning "we need to be careful to not go too far."

An accompanying JBJS article, "The Orthopaedic Work Force: Which Rate is Right?," also points to limitations of the methodology. The article, co-authored by James N. Weinstein, DO; David Goodman, MD; and John Wennberg, MD, of the Center for the Evaluative Clinical Sciences, Dartmouth Medical School, says basing work force projections on utilization rates assumes that "demand is determined by illness rates and access to care independent of the systems that provide the care, and, therefore, can be used to project supply needs.

"The findings of small area variation studies contradict that assumption."

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