• Work Force Overview - - - - - - - - - - - - - - - - - - Ronald P. Kaufman. M.D.• How to Interview and Assess Opportunities - - Janie Hirsch• Contract Negotiations - - - - - - - - - - - - - - - - - - William Kalist, J.D.

• Ten (10) 1 hour noon conferences from October 8, 2002 through February 19, 2003 at VA and TGH, covering:

• Pros and Cons of a Large Multi-specialty Group Practice• Small Group Practice• Leaving One Practice and Joining Another or Going into Solo Practice• How to Avoid Malpractice Suits• Proper Way to Apply for Full Medical Licensure in the State of Florida• Basic Financial Terms Part I• Basic Financial Terms Part II – will cover student loan repayment• Pursuit of Perfection• Gross Earnings vs. Spendable Income• Personal Financial Planning

• Risk Management – i.e. Malpractice Issues• Government Compliance Requirements• H.I.P.A.A.

Outline of Program “Getting A Job”

Students

Residents

SOURCE: AAMC Data Warehouse

31,137

38,529

41,003

43,020

46,968

46,591

45,365

42,808

37,410

33,301

29,243

31,137

38,529

41,003

43,020

46,968

46,591

45,365

42,808

37,410

33,301

29,2431990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

SOURCE: AAMC DATA Warehouse: 2000 Applicant Matriculant File

74737412

7162

6851

64336153

6772

6819694169186995

3000 4000 5000 6000 7000 8000

19901991199219931994199519961997199819992000

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

Net increase in U.S. medical graduatesentering the work force

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2020

2012

2014

2016

2018

2020

* Graduates are projected to retire after 35 years of practice.** Graduates from 1997-2020 are estimated to remain constant.

Estimated Retirements* National Graduates**

Source: MGT of America, Inc.From Assessment of the Adequacy andCapacity of Florida’s Medical Education System, 1999

YEAR M.D. DO DO as GRANTING GRANTING % of TOTAL

1970 40,487 2,151 5.0%1975 55,818 3,443 5.8%1980 65,189 4,940 7.0%1985 66,585 6,608 9.0%1990 65,163 6,792 9.4%1995 67,276 8,961 11.7%

26%

40%

20%14%Less than $50,000

$50,000 to $99,999

$100,000 to 149,999

$150,000 or more

Source: 1999 Medical School Graduation Questionnaire, All Schools Report - AAMC

80%

61%

21%

17%

15%

6%

15%

19%

26%

46%

89%

5%

Location

Financial package

Call/coverage

Lifestyle amenities

Loan forgiveness

Specialty support

(% ranking it first or second)

SOURCE: Merritt, Hawkins & Associates1999 Survey of Final-Year Medical Residents

1999

1997

(% citing it)

33% Multi-specialty group 25%29 Single-specialty group 3113 Partnership 15 4 Hospital employee 8 6 Outpatient clinic 8 2 Solo 4 5 Association ¹ 2 5 HMO 1 5 Other ² 6

1997 1999

¹ An arrangement whereby physicians share staff and office, but not finances.² Includes academic, locum tenens, urgent care, and no preference.

Source: Merritt, Hawkins & Associates 1999Survey of Final-Year Medical Residents

1995 199734%

22%

14%

14%

12%

3%

Finding a job Right practice setting Indebtedness Having free time

Malpractice climate Managed care Medicine as a career Health reform

1999

SOURCE: Merritt, Hawkins& Associates 1999 Survey of Final-Year Medical Residents

32%

21%

15%

13%

7%

5%

1%

FINDING A JOB31%

18%

13%

11%

10%

7%

FINDING A JOBRight Practice Setting

2% Anesthesiologists 10% 3% Radiologists 16% 3% Psychiatrists 16%10% Emergency medicine 4%11% IMs 8% 17% Others 22%54% FPs/GPs 13% Pediatricians 2% Cardiologists 2% Orthopedic Surgeon 3% Child psychiatrists 4%

1997 2001

NumberOf

DoctorsNeeded

U.S. Total needed12,098

U.S. Total needed12,098

The top 10 states with shortages of primary care doctors

Source: Bureau of Primary Health Care, Health Resources & Services Admin, US Dept. of Health and human Services

Texas1,103

Calif.757

Ohio372

N.Y.824

Mo.406

Ga.530

Ala.445

Ill.381

Mich.489

Fla. 631

U.S. Overall227

Idaho144

PhysiciansPer

100,000In

population

Alaska154

Nev.160

Okla.155

Wyo.156

Miss.148

Iowa156

S. D.170

Ark.175

Ind.178

States with the lowest doctor-to-population ratios

Source: American Medical Association

HMOpenetration

rate

States with the lowest HMO enrollment as a % of total population

Source: InterStudy Publications, US Census Bureau

United States (overall penetration) 29.7%

Alaska0%

Idaho.7.9%

Miss.1.1%

S.D.6.7%

Ala.7.2%

N.D.2.5%

Mont.7.0%

Iowa7.4%

Wyoming1.4%

VT4.6%

States with most physicians per capita States with fewest physicians per capita

District of

Columbia 811

Massachusetts 454

Maryland 413

New York 423

Connecticut 387

Idaho 179

Mississippi 180

Oklahoma 187

Alaska 186

Wyoming 188

• Job opportunities not as readily available as in the past

• Varies by specialty and varies by geography

• Shifts year to year• in demand• in compensation• in specialty opportunities

• Primary Care - demand and compensation flat

• Selective specialty demands will grow:• increase in procedural technology and demand

• radiology; cardiology; G.I.• increase in early retirement• aging of America

Reproduced from Lohr and Colleagues (5)

0

200

400

600

800

1000

1200

1400

1950 1960 1970 1980 1990 2000 2010 2020

Physicians per 100,000 Population

142.2 141.6

155.8

195.9

236.9

260.7

274.4

266.0

Su

pp

ly (

1000

s)

300.0

250.0

200.0

150.0

100.0

50.0

0.0

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

STUDY DATE CONCLUSION

Harry Truman 1945 ShortagePresident’s Commission 1953 ShortageBane Commission 1959 ShortageGMENAC 1980 SurplusCOGME 1988 SurplusBHP 1988 SurplusAMA 1988 ShortageCOGME 1993 SurplusPPRC 1993 SurplusPew Commission 1995 SurplusCOGME 1995 Specialist SurplusIOM 1996 Geographic VariationsSACHS 1996 Specialist Surplus/PCP ShortageJAMA 1996 Geographic VariationsCOGME 1997 SurplusAcademic Consensus 1997 SurplusMed PAC 1999 GME payment reform

DEFINITIONS:

GMENAC -Graduate Medical Education National Advisory Committee

COGME - Council on Graduate Medical Education

BHP - Bureau of Health Professionals

PPRC - Physician Payment Review Commission

Med PAC - Medicare Payment Advisory Commission

1929 2000 2010 2020

Physicians, total 144,000 772,000 887,300 964,700

Physicians/100,000 pop. 119 270 283 280

Population (in Millions) 121 286 325 345

Effective supply adjustment - 5% -7%

Storage of physicians 50,000 200,000

2010 and 2020 projected using Cooper, et al, Trend Model; assumes 1st-year residents holds steady at 23,000 a year, 20% of IMGS return to home country, and current retirement trends continue.Adjustment due to reduced work effort, including a 10% reduction in production by physicians ages 55 to65 and a 20% production reduction in women physicians (American Journal of Public Health, 1990).

Source: Health Affairs, January/February

I specialize in referrals to Specialists.

411

477523

577611687

267

271

237220195169

0

100

200

300

400

500

600

700

800

‘75 ‘79 ‘80 ‘83 ‘85 ‘87 ‘90 ‘91 ‘95 ‘96

Source: Kaiser Family Foundation analysis of American Hospital Association and U.S. Bureau of the Census data;and American Medical Association, Physician Characteristics and Distribution in the U.S., 1997-98 Edition.

Hospital Beds

Physicians

90,000

110,000

130,000

150,000

170,000

Source: AMA

$94,000

$100,000 $108,000

$120,000$125,000

$130,000 $139,000

$148,000$156,000

$150,000$160,000

$166,000

$164,000

(MGMA) Physician Compensation and Production Survey 1998 Report Based on 1997 Data

1991 1992 1993 1994 1995 1996 1997 1998

$500,000

$400,000

$300,000

$200,000

$100,000

Surgery: Cardiovascular

Cardiology: Invasive

Surgery: Orthopedic

Radiology: Diagnostic

Cardiology: Non-invasive

OBGYN

Surgery: General

Neurology

Internal Medicine

Pediatrics

Family Practice

195 (18) 151

(50

171(37)

189(31)

139(48)

157(45

151(44)183

(33)180(32)

147(47)

160(43)

146(46) 176

(35)206(16)

182(25)

180(30)

142(49)

173(40)

203(23)

130(51)

170(41)

180(36)

197(27)

208-(20) 176(38)

194(24)

180(39)

166(42)

200(22)

196(26)

190(29)

NH-189 (19)

NJ-249 (8)

202(15)

High Physician Concentration Areas

217(11)

203 (12)

221(14)

215(13)

208(17)

316(3)

246(9)

DC - 536 (1)

ME-182 (28)VT- 242 (7)

MA-332 (2)RI-267 (6)

M.D.- 299 (4)Del-197 (21)

CT-295 (5)

Source: AMA, Physician Characteristics & Distribution in the US,1996-97

Ratio of Physicians/100,000 Population

228(10)

179(34)

Low Concentration

Wash.

19%

Ore.Ore.

39%39% Idaho

7%

Mont.

5%

Wyo.

3%

S.D.5%

Iowa13% Neb.

11%

Kan.19%

Okla.15%

Ark.12%

Calif.

55%Calif.

55%

Nev.Nev.

25%25% Utah

37% Utah

37% Colo.

38%

Colo.

38% Ariz.

32% Ariz.

32% N.M.

37% N.M.

37%Alaska0%

Hawaii 45%

Texas

19% La. 17%

Miss.4%

Fla.33%

Ala.7%

Ga. 18%

Mo.31% Mo.31%

Tenn. 40%Tenn. 40%S.C. 12%

N.C. 17%

Va. 21% Va. 21%

W.V. 11%

Ky.38% Ky.38%

Ill.20%

Ind.17%

Ohio25%Ohio25%

Minn.

29% Minn.

29% Wis.31% Wis.31% Mich.

27%Mich. 27%

N.Y.38% N.Y.38%

Me.24% Me.24%Vt. 26%

N.H. 34%Mass. 42%R.I. - 50%

N.J.-29%

Md. - 34%Del. - 49%

Pa.45% Pa.45%

Conn.- 41%

All HMOs: 25% Source: Medical Data International Inc., April 2000

31% - 100% 21% - 30% 11% - 20% 0% - 10%

N.D.3%

MountainMountain$151,000$151,000

MountainMountain$151,000$151,000

West CentralWest Central$160,000$160,000

West CentralWest Central$160,000$160,000

New EnglandNew England$140,000$140,000

New EnglandNew England$140,000$140,000

Mid-Mid-AtlanticAtlantic$173,000$173,000

Mid-Mid-AtlanticAtlantic$173,000$173,000

East NorthEast NorthCentralCentral$164,000$164,000

SouthSouthAtlanticAtlantic$164,000$164,000

SouthSouthAtlanticAtlantic$164,000$164,000East SouthEast South

CentralCentral$175,000$175,000

East SouthEast SouthCentralCentral$175,000$175,000

PacificPacific$165,000$165,000

Source: Integrated Healthcare Report

110

120

130

140

150

160

170

Source: American Hospital Association

NOMINALREAL (1998 $)

($ In Thousands)

No shortage of Primary Care

No excess of Specialists

Decreasing interest in:• Internal Medicine• Pediatrics• Family Medicine

Geographic mal-distribution• Shift to the suburbs • Shift away from rural & inner city

Experts have been wrong in the past

Market adjusts

Technology

New Pathologies

Demographic changes

Consumerism

HMO?

IDS?

IPA? PA?

MSO?

*!#@?*

PHO? PPMC?

• Self-employed solo 25.9%• Self-employed group 30.7%• Employee:

Health maintenance organization 2.7%

Group practice, free-standing center 11.1%

Private hospital 7.3%

Medical schools, universities, colleges 7.0%

State and local government 9.6%

Unknown 1.1%• Independent contractor 4.7% *

1997 DISTRIBUTION OF PHYSICIANS BY PRACTICE TYPE AND EMPLOYER*

Source: AMA Center for Health Policy Research

Percentages do not sum to 100 because of rounding

Source: AMA Center for Health Policy Research

The AMA votes to organize a unionTOO MUCH FOR TOO FEW?AMA leaders say only a fraction ofpracticing physicians would beeligible to participate in an AMA-run collective bargaining unit:

The 290,000-member association -- whichrepresents 34 % of the nation’s doctors, down from 45% a decade ago -- also felt pressure to act because some of the most powerful unions have moved aggressively toorganize doctors, eroding the AMA’s base and making it seem timid to its members. Specifically, the AMA voted to set up a branch to unionize two groups of doctors, salaried employees and medical residents, who together represent about 1/3 of America’s 620,000 practicing physicians. The association also said it would work to unionize some of the 325,000 self-employed doctors, but to do that it must persuade Congress to give those doctors the right to bargain collectively. Eager to reassure patients, AMA See UNION, Page 7

CHICAGO - The American Medical Association bows to a growing chorus of physicians who say they lack power in managed care.

A Tribune staff, wire report

The American Medical Association,saying doctors are frustrated in efforts to deliver quality care, took the extraordinary step of forming a labor union Wednesday to give physicians more power in dealing with managed care insurers. For the 152-year old AMA, long one ofthe nation’s most conservative institutions,the vote at a delegates meeting represent-ed an angry outcry by doctors who complainthey have lost too much power in today'shealth care system.

Institutional Employees 26.6%

Employeesof MD-owned

Groups9.4%

Self-employedMDs64%

National Labor Relations Board v. Kentucky River Community Care, Inc.

Venue: U. S. Supreme Court

At Issue: The court said a professional who uses “independent judgment to direct the workof others is a supervisor who is unable to collectively bargain.

Potential Impact: The decision is expected tomake it more difficult for privately employedphysicians to unionize.

Source: National Conference of State Legislatures Pending legislationLegislation enacted

Source: Merritt, Hawkins & Associates

ManagedCare

56%

Medicare/Medicaid

regulation/billing: 15%

Patient attitudes: 8%

Malpractice worries: 6%

Pressure of running

a business: 6%

Long hours: 4%

Other: 5%

Retire38%

Retire38%

Continue as you are: 18%

Close your practice to new patients or significantly reduce

work load: 16%

Work locum tenens: 12%

Seek employment in non-clinical or non-medical

setting: 10%

Other: 4% Source: Merritt, Hawkins & Associates

N.E.J.M., Vol. .344, No. 3January 18, 2001

Clinicalknowledge

and skill

Understanding the health care system

Advocacyand

accountabilityfor

individualsand panels

Organizedpractice

managementsystems

Stewardship: Appropriate allocation of health careresources for quality care and cost effectiveness

• current and future opportunities and concerns

Outlined the program and its goals and objectives

Offered trend data on:

• numbers of M.D.s

• market forces at play

• compensation trend

• forces impacting choice