Physician Workforce 

Policy Guidelines for the 

United States,

2000-2020

COUNCIL ON GRADUATE MEDICAL EDUCATION

Sixteenth Report

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

January 2005

Physician Workforce 

Policy Guidelines for the 

United States,

2000-2020

COUNCIL ON GRADUATE MEDICAL EDUCATION

Sixteenth Report

January 2005

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration
SIXTEENTH REPORT OF COGME ii 

The views expressed in this document are solely those of the

Council on Graduate Medical Education and do not

necessarily represent the views of the

Health Resources and Services Administration

nor the U.S. Government.
SIXTEENTH REPORT OF COGME iii

Table of Contents

 Page

The Council on Graduate Medical Education...........................................................................................ix

Members of the Council on Graduate Medical Education ........................................................................xi

Preface......................................................................................................................................................xiii

Summary and Recommendations........................................................................................................................xv

Key Findings..................................................................................................................................................xv

Recommendations..........................................................................................................................................xvii

Related Issues of Concern..............................................................................................................................xx

Background ...........................................................................................................................................................1

Supply of Physicians, 2000-2020..........................................................................................................................3

Overview of Methodology: Baseline Model and Factors Affecting Future Supply ......................................3

New Entrants..............................................................................................................................................4

Women in Medicine...................................................................................................................................6

Aging of the Physician Workforce.............................................................................................................7

Separation From the the Physician Workforce ..........................................................................................7

Specialty Distribution and Choices............................................................................................................7

Activity Rates ............................................................................................................................................7

Alternative Supply Scenarios and Assumptions.............................................................................................8

Alternative Scenario One: Lifestyle Changes............................................................................................8

 Sensitivity Analysis: Alternative Scenario One ..................................................................................9

Alternative Scenario Two: Productivity Changes......................................................................................10

 Sensitivity Analysis: Alternative Scenario Two..................................................................................11

Alternative Scenario Three: Hybrid Lifestyle/Productivity Changes........................................................12

 Sensitivity Analysis: Alternative Scenario Three ...............................................................................12

Conclusions: Supply of Physicians in the U.S., 2000-2020...........................................................................12

Future Demand for Physicians, 2000-2020.........................................................................................................15

Overview of Methodology: Baseline Model and Factors Affecting Future Demand ....................................15

Alternative Demand Scenarios and Assumptions ..........................................................................................16

Alternative Scenario One: Economic Factor .............................................................................................16

 Sensitivity Analysis: Alternative Scenario One ..................................................................................17

 Alternative Scenario Two: Changes in Age-Specific Utilization Rates.....................................................18

 Sensitivity Analysis: Alternative Scenario Two..................................................................................21

 Alternative Scenario Three: Elimination of Unnecessary Services/Increased Utilization Review ...........22

 Sensitivity Analysis: Alternative Scenario Three ...............................................................................23

 Alternative Scenarios Four and Five: Hybrid Models—Economic Expansion and 

 Unnecessary Services/Increased Utilization Review; Changes in Age-Specific Utilization Rates and 

 Unnecessary Services/Increased Utilization Review.................................................................................24

Conclusions: Demand for Physicians in the U.S., 2000-2020 .......................................................................25

Future Need for Physicians, 2000-2020...............................................................................................................27

Overview of Methodology: Baseline Model and Factors Affecting Future Need .........................................27

Alternative Need Scenarios and Assumptions................................................................................................28

Alternative Scenario One: Changes in Age-Specific Utilization Rates.....................................................28

 Sensitivity Analysis: Alternative Scenario One ..................................................................................28
SIXTEENTH REPORT OF COGME iv 

 Alternative Scenario Two: Elimination of Unnecessary Services/Increased Utilization Review..............29

 Sensitivity Analysis: Alternative Scenario Two..................................................................................29

 Alternative Scenario Three: Changes in Age-Specific Utilization Rates; 

 Unnecessary Services/Increased Utilization Review Hybrid ....................................................................29

 Sensitivity Analysis: Alternative Scenario Three ...............................................................................30

Conclusions: Need for Physicians in the U.S., 2000-2020 ............................................................................31

Physician Supply, Demand, and Need, 2000-2020: Specialty Mix Issues ........................................................33

Supply of Generalist and Non-Generalist Physicians: Baseline Projections.................................................33

 Supply Specialty Mix Alternative Scenario One: Non-Generalist Dominant Mix....................................34

 Supply Specialty Mix Alternative Scenario Two: Generalist-Weighted Mix............................................34

Demand for Generalist and Non-Generalist Physicians: Baseline Projections..............................................34

 Demand Specialty Mix Alternative Scenario One: Non-Generalist Dominant Demand Mix...................36

 Demand Specialty Mix Alternative Scenario Two: Generalist-Weighted Mix..........................................36

Need for Generalist and Non-Generalist Physicians......................................................................................37

 Need Specialty Mix Alternative Scenario One: Non-Generalist Dominant Need Mix .............................38

 Need Specialty Mix Alternative Scenario Two: Generalist-Weighted Mix...............................................38

Issues Beyond the Models.....................................................................................................................................41

Resident and Fellow Work-Hour Restrictions................................................................................................41

Non-Physician Clinicians (NPCs)..................................................................................................................41

Boutique Medicine .........................................................................................................................................41

Conclusions: Physician Supply, Demand, and Need in the U.S., 2000-2020....................................................43

Supply ............................................................................................................................................................43

Demand ..........................................................................................................................................................43

Need ...............................................................................................................................................................44

Summary ........................................................................................................................................................44

References..............................................................................................................................................................45
SIXTEENTH REPORT OF COGME v

Tables and Figures

 Page

Table 1. Supply of Physicians in the U.S., 2000-2020: Baseline Projections........................................................4

Table 2. Projected Number of New Entrants Into the Physician Supply, 2000-2020 ........................................5

Table 3. FTE-to-Physician Ratio, 2000-2020 ...............................................................................................7

Table 4. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario One 

 Projections: Physician Lifestyle Changes................................................................................................9

Table 5. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario One 

 Projections of Physician Lifestyle Changes: Sensitivity Analysis...........................................................10

Table 6. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario Two 

 Projections: Physician Productivity Increases.........................................................................................11

Table 7. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario Two 

 Projections of Physician Productivity Increases: Sensitivity Analysis....................................................11

Table 8. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario Three 

 Projections: Hybrid Lifestyle/Productivity Changes...............................................................................12

Table 9. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario Three 

 Projections of Hybrid Lifestyle/Productivity Changes: Sensitivity Analysis..........................................13

Table 10. Demand for Physicians in the U.S., 2000-2020: 

 Baseline Projections...............................................................................................................................16

Table 11. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario One 

 Projections: Economic Factor................................................................................................................18

Table 12. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario One 

 Projections of Economic Factor: Sensitivity Analysis...........................................................................18

Table 13. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario Two 

 Projections: Changes in Utilization Rates .............................................................................................21

Table 14. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario Two 

 Projections of Changes in Utilization Rates: Sensitivity Analysis........................................................22

Table 15. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario Three 

 Projections: Reduction of Unnecessary Services...................................................................................23

Table 16. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario Three 

 Projections of Reduction of Unnecessary Services: Sensitivity Analysis .............................................24

Table 17. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario Four 

 Projections: Economic Factor/Increased Utilization Review ................................................................24
SIXTEENTH REPORT OF COGME vi 

Table 18. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario Five 

 Projections: Changes in Utilization Rates/Increased Utilization Review..............................................25

Table 19. Need for Physicians in the U.S., 2000-2020: Baseline Projections.......................................................27

Table 20. Need for Physicians in the U.S., 2000-2020, Alternative Scenario One 

 Projections: Changes in Utilization Rates .............................................................................................28

Table 21. Need for Physicians in the U.S., 2000-2020, Alternative Scenario One 

 Projections of Changes in Utilization Rates: Sensitivity Analysis........................................................29

Table 22. Need for Physicians in the U.S., 2000-2020, Alternative Scenario Two 

 Projections: Reduction of Unnecessary Services...................................................................................30

Table 23. Need for Physicians in the U.S., 2000-2020, Alternative Scenario Two 

 Projections: Sensitivity Analysis ...........................................................................................................30

Table 24. Need for Physicians in the U.S., 2000-2020, Alternative Scenario Three 

 Projections: Changes in Utilization Rates/Increased Utilization Review..............................................31

Table 25. Need for Physicians in the U.S., 2000-2020, Alternative Scenario Three 

 Projections: Sensitivity Analysis ...........................................................................................................31

Table 26. Supply of Physicians in the U.S., 2000-2020: Baseline Specialty Projections..................................33

Table 27. Supply of Physicians in the U.S., 2000-2020, Specialty Projections: 

 30% Generalist/70% Non-Generalist Scenario......................................................................................34

Table 28. Supply of Physicians in the U.S., 2000-2020, Specialty Projections: 

 45% Generalist/55% Non-Generalist Scenario......................................................................................35

Table 29. Demand for Physicians in the U.S., 2000-2020, Baseline Specialty Projections..................................35

Table 30. Demand for Physicians in the U.S., 2000-2020, Specialty Projections: 

 30% Generalist/70% Non-Generalist Scenario......................................................................................36

Table 31. Demand for Physicians in the U.S., 2000-2020, Specialty Projections: 

 45% Generalist/55% Non-Generalist Scenario......................................................................................37

Table 32. Need for Physicians in the U.S., 2000-2020: Baseline Specialty Projections.......................................37

Table 33. Need for Physicians in the U.S., 2000-2020, Specialty Projections: 

 30% Generalist/70% Non-Generalist Scenario......................................................................................39

Table 34. Need for Physicians in the U.S., 2000-2020, Specialty Projections: 

 45% Generalist/55% Non-Generalist Scenario......................................................................................39

* * *
SIXTEENTH REPORT OF COGME vii

Figure 1. Total Number of Allopathic and Osteopathic Graduates, 1980-2020 ....................................................5

Figure 2. Change in Medical Students, Population, and Students per Population, 1980-2020 .............................6

Figure 3. Age Distribution of Active Allopathic Physicians in the U.S., 1982 and 2001......................................8

Figure 4. PDM Population/Delivery Setting Matrix (Simplified) .........................................................................15

Figure 5. Relationship Between Active Physician Supply and GDP, 1929-2000..................................................17

Figure 6. Number of Americans 65 and Over and 85 and Over, 2000-2030 .........................................................19

Figure 7. Days of Care in Short-Stay Hospitals, 1999...........................................................................................20

Figure 8. Estimates of Ambulatory Care Visits to Physician Offices and Clinics 1980, 1990, and 2000 .............20

Figure 9. Physician Supply, Demand, and Need in the U.S., 2020........................................................................43
SIXTEENTH REPORT OF COGME viii 
SIXTEENTH REPORT OF COGME ix

The Council on Graduate Medical Education

The Council on Graduate Medical Education (COGME) 

was first authorized by Congress in 1986 to provide an 

ongoing assessment of physician workforce trends, training 

issues, and financing policies and to recommend appropriate 

Federal and private-sector efforts to address identified 

needs. The legislation calls for COGME to advise and make 

recommendations to the Secretary of the Department of 

Health and Human Services (DHHS); the Senate Committee 

on Health, Education, Labor, and Pensions; and the House 

of Representatives Committee on Commerce. Section 219 of 

the Department of Labor, Health and Human Services, and 

Education and Related Agencies’ Appropriations Act, 2004, 

Public Law 102-394, 106 Stat. 1825, resulted in the Secretary 

of DHHS extending COGME through the end of the fiscal year.

The legislation specifies 17 members for the Council. 

Appointed individuals are to include representatives of practicing primary care physicians, national and specialty physician organizations, international medical graduates, medical 

student and house staff associations, schools of medicine and 

osteopathy, public and private teaching hospitals, health insurers, business, and labor. Federal representation includes the 

Assistant Secretary for Health, DHHS; the Administrator of 

the Centers for Medicare and Medicaid Services, DHHS; and 

the Chief Medical Director of the Veterans Administration.

CHARGE TO THE COUNCIL

The charge to COGME is broader than the name would 

imply. Title VII of the Public Health Service Act, as amended, 

requires COGME to provide advice and recommendations to 

the Secretary of DHHS and Congress on the following issues:

1. The supply and distribution of physicians in the 

United States;

2. Current and future shortages or excesses of 

physicians in medical and surgical specialties and 

subspecialties;

3. Issues relating to international medical school 

graduates;

4. Appropriate Federal policies with respect to 

the matters specified in items 1-3, including 

policies concerning changes in the financing of 

undergraduate and graduate medical education 

(GME) programs and changes in the types of 

medical education training in GME programs.

5. Appropriate efforts to be carried out by hospitals, 

schools of medicine, schools of osteopathy, and 

accrediting bodies with respect to the matters 

specified in items 1-3, including efforts for changes 

in undergraduate and GME programs; and

6. Deficiencies and needs for improvement in 

databases concerning the supply and distribution 

of, and postgraduate training programs for, 

physicians in the United States and steps that 

should be taken to eliminate those deficiencies.

In addition, the Council is to encourage entities providing GME to conduct activities to achieve voluntarily 

the recommendations of the Council specified in item 5.

COGME PUBLICATIONS

Since its establishment, COGME has submitted the 

following reports to the Secretary of DHHS and Congress:

Reports

• First Report of the Council (1988);

• Second Report: The Financial Status of Teaching 

Hospitals and the Underrepresentation of Minorities 

in Medicine (1990);

• Third Report: Improving Access to Health Care 

Through Physician Workforce Reform: Directions 

for the 21st Century (1992);

• Fourth Report: Recommendations to Improve 

Access to Health Care Through Physician Workforce 

Reform (1994);

• Fifth Report: Women and Medicine (1995);

• Sixth Report: Managed Health Care: Implications 

for the Physician Workforce and Medical Education 

(1995);

• Seventh Report: Physician Workforce Funding 

Recommendations for Department of Health and 

Human Services’ Programs (1995);

• Eighth Report: Patient Care Physician Supply and 

Requirements: Testing COGME Recommendations 

(1996);

• Ninth Report: Graduate Medical Education 

Consortia: Changing the Governance of Graduate 

Medical Education to Achieve Physician Workforce 

Objectives (1997);
SIXTEENTH REPORT OF COGME x 

• Tenth Report: Physician Distribution and Health 

Care Challenges in Rural and Inner-City Areas 

(1998); 

• Eleventh Report: International Medical Graduates, 

The Physician Workforce and GME Payment 

Reform (1998);

• Twelfth Report: Minorities in Medicine (1998);

• Thirteenth Report: Physician Education for a 

Changing Health Care Environment (1999);

• Fourteenth Report: COGME Physician Workforce 

Policies: Recent Developments and Remaining 

Challenges in Meeting National Goals (1999); and

• Fifteenth Report: Financing Graduate Medical 

Education in a Changing Health Care Environment 

(2000).

OTHER COGME PUBLICATIONS

• Scholar in Residence Report: Reform in Medical 

Education and Medical Education in the Ambulatory 

Setting (1991);

• Process by which International Medical Graduates 

are Licensed to Practice in the United States 

(September 1995);

• Proceeding of the GME Financing Stakeholders 

Meeting (April 11, 2001) Bethesda, Maryland;

• Public Response to COGME’s Fifteenth Report 

(September 2001);

• Council on Graduate Medical Education & National 

Advisory Council on Nurse Education and Practice: 

Collaborative Education to Ensure Patient Safety 

(February 2001);

• Council on Graduate Medical Education: What is 

it? What has it done? Where is it going? 2nd Edition 

(2001); and

• 2002 Summary Report (2002).

COGME RESOURCE PAPERS

• Preparing Learners for Practice in a Managed Care 

Environment (1997);

• International Medical Graduates: Immigration 

Law and Policy and the U.S. Physician Workforce 

(1998);

• The Effects of the Balanced Budget Act of 1997 on 

Graduate Medical Education (2000);

• Update on the Physician Workforce (2000);

• Evaluation of Specialty Physician Workforce 

Methodologies (2000); and

• State and Managed Care Support for Graduate 

Medical Education: Innovations and Implications 

for Federal Policy (2004).

For more information on COGME, visit the Council’s 

Web site at:

http://www.cogme.gov or contact:

Council on Graduate Medical Education

5600 Fishers Lane, Room 9A-21

Rockville, MD 20857

Voice: (301) 443-6326

Fax: (301) 443-8890
SIXTEENTH REPORT OF COGME xi

Members of the Council on Graduate 

Medical Education

Members

 

Chair

Carl J. Getto, M.D.

Senior Vice President Medical Staff Affairs/Associate

 Dean Hospital Affairs

University of Wisconsin Hospital & Clinics

Madison, Wisconsin

Vice Chair

Robert L. Johnson, M.D., Professor of Pediatrics and 

Vice Chair, Department of Pediatrics

New Jersey Medical School

Division of Adolescent and Young Adult Medicine

Newark, New Jersey

Ms. Laurinda L. Calongne

President

Robert Rose Consulting

Baton Rouge, Louisiana

William Ching, Medical Student

New York University School of Medicine

New York, New York

Allen Irwin Hyman, M.D., FCCM

Executive Vice President and Chief of Staff

Columbia-Presbyterian Medical Center

New York, New York

Rebecca M. Minter, M.D.

VAMC Ann Arbor Healthcare System

Surgery Service 

Ann Arbor, Michigan

Lucy Montalvo, M.D., M.P.H.

San Diego, California

Angela D. Nossett, M.D.

Executive Vice President

Committee of Interns and Residents (CIR)

Wilmington Family Health Center

Wilmington, California

Earl J. Reisdorff, M.D.

Director of Medical Education

Ingham Regional Medical Center

Department of Medical Education

Lansing, Michigan

Russell G. Robertson, M.D.

Department of Family and Community Medicine

Medical College of Wisconsin

Milwaukee, Wisconsin

Jerry Alan Royer, M.D., M.B.A.

229 Cascade Falls Drive

Folsom, California

Susan Schooley, M.D.

Chair, Department of Family Practice

Henry Ford Health System

Detroit, Michigan

Humphrey Taylor, Chairman

The Harris Poll, Harris Interactive

New York, New York

Douglas L. Wood, D.O., Ph.D., President

American Association of Colleges

of Osteopathic Medicine

Chevy Chase, Maryland

Statutory Members

Cristina Beato, M.D.

Acting Assistant Secretary for Health

and Surgeon General

Washington, D.C. 

Mark B. McClellan, M.D., Ph.D.

Administrator, Centers for Medicare and

 Medicaid Services

Department of Health and Human Services

Washington, D.C. 

Robert H. Roswell, M.D.

Undersecretary for Health

Veterans Health Administration

Department of Veterans Affairs

Washington, D.C.

Designee of the Acting Assistant 

Secretary for Health

Howard Zucker, M.D., Deputy Assistant

Secretary for Health 

Department of Health and Human Services

Washington, D.C. 
SIXTEENTH REPORT OF COGME xii 

Designee of the Centers for Medicare and 

Medicaid Services

Tzvi M. Hefter, Director 

Division of Acute Care

Centers for Medicare and Medicaid Services

Baltimore, Maryland

Designee of the Department of 

Veterans Affairs

Stephanie H. Pincus, M.D., M.B.A.

Chief Academic Affiliations Officer

Department of Veterans Affairs

Washington, D.C.

Staff, Division of Medicine and Dentistry,

Bureau of Health Professions, HRSA

Department of Health and Human Services

Rockville, Maryland

Tanya Pagán Raggio, M.D., M.P.H.

Executive Secretary and

Director, Division of Medicine and Dentistry (DMD)

O’Neal Walker, Ph.D.

Chief, Dental and Special Projects Branch/DMD

Jerald M. Katzoff

Deputy Executive Secretary

C. Howard Davis, Ph.D.

Staff Liaison

Jaime Nguyen, M.D., M.P.H.

Staff Liaison

Eva M. Stone

Program Analyst and Committee Management Specialist

Anne Patterson

Secretary

Contractor for Report Preparation: 

Edward Salsberg and Gaetano Forte

The Center for Health Workforce Studies

State University of New York at Albany
SIXTEENTH REPORT OF COGME xiii

Preface

A central charge of the Council on Graduate Medical 

Education (COGME) is to make policy recommendations 

to the Nation with respect to the adequacy of the supply 

and distribution of physicians in the United States (U.S.). 

This mandate includes recommendations on current and 

future shortages or excesses of physicians in the medical and surgical specialties and subspecialties. Beginning 

in 1992, with its Third Report, COGME issued a series 

of reports expressing concern with potential surpluses of 

physicians and recommending an increase in the percent 

of physicians trained and practicing as generalists. These 

concerns led the Council to develop a recommendation 

that 110 percent of the number of U.S. medical graduates 

in 1993 should enter residency training each year (or about 

19,750 physicians) and that half of these physicians should 

be generalists. This recommendation became known as the 

“110/50-50” goal for the physician workforce in the U.S.

In response to changes in the health care delivery 

system, demographic changes in the Nation’s population, 

changes in the practice of medicine, and other developments, 

the Council concluded in 2002 that it was appropriate and 

timely to re-assess the current and future supply, demand, 

and need for physician services in America. The following report is the result of this most recent re-assessment. In 

light of limited resources, this study primarily used existing 

models to forecast physician supply and demand, but also 

used more current data unavailable for prior assessments.

The Nation’s physician workforce is critical to the delivery of health care to Americans. In consideration of this 

role and the high cost of educating and training the physician 

workforce, ongoing tracking of workforce needs and periodic 

comprehensive assessments are essential to guiding decisions 

by the medical education community, prospective physicians, 

policy makers, and others concerned with Americans’ health. 

The Council hopes that this report will provide this guidance.
SIXTEENTH REPORT OF COGME xiv 
SIXTEENTH REPORT OF COGME xv

Summary and Recommendations

The Council on Graduate Medical Education (COGME) 

assessed the likely future supply, demand, and need for physicians in the United States (U.S.) through 2020 for both generalist and non-generalist physicians. The models used for 

the projections are based on historical patterns of use of services and physician practice patterns applied to the expected 

U.S. population and the physician workforce through 2020. 

Where changes are occurring or have occurred in the historic 

patterns, this report incorporates the best available information and discusses their likely implications. The models 

used build on the physician forecasting models of the Health 

Resources and Services Administration (HRSA)/Bureau of 

Health Professions (BHPr).1 The use of these models helps 

to ensure some consistency with prior work and facilitates 

comparisons of the new forecasts with prior forecasts.

Scenarios have been constructed around the best understanding of changes occurring in health care and in medicine. 

For each scenario, the report presents a sensitivity analysis indicating what the impact might be if that factor were to change to 

a lesser or greater extent than current understanding portends.

The report forecasts future supply based on the age, 

gender, specialty distribution, and educational background 

of the existing supply and current trends in new entrants 

into residency training from U.S. allopathic and osteopathic schools, from Canadian medical schools, and from 

foreign medical schools. The report also forecasts future 

demand and need for physician services based on the 

historical patterns of use of services by age, gender, insurance status, type of area (urban or rural), and managed care 

penetration. Estimates of future need are based primarily 

on the assumption that the use of physician services by the 

uninsured would increase to the level of those with health 

insurance if resources were available to meet their needs. 

It is also assumed that the removal of other barriers to 

use would also contribute to some increase in service use. 

Further, the report presents an analysis of supply, demand, 

and need for generalist and non-generalist specialties.2

This report includes the results of the data analysis and describes methodologies used to forecast supply, demand, and need and the potential impact of 

changes in the factors that influence each of those. The 

report also includes recommendations to better assure 

that the future supply meets future demand and need.

1 They include the Physician Supply Model (PSM) and the Physician Demand Model (PDM), previously known as the Integrated Requirements Model 

(IRM).

2 For purposes of this report, generalists are defined as family physicians, general internists, pediatricians, physicians trained in combined internal medicine 

and pediatrics programs, and general practitioners. Non-generalists are defined as all other physicians.

3 Unless otherwise indicated, the physician counts in this report for supply, demand, and need refer to FTE physicians. FTEs are based on the number of 

hours physicians are or are expected to be working and are adjusted to account for the demographics of the physician population. The physician figures also 

include all active physicians and all time spent in medical activities, including non-patient care activities, and all physicians in training.

KEY FINDINGS

1. Under current production and practice patterns, 

the supply of practicing physicians in the U.S. is 

expected to rise from 781,200 full-time equivalent 

(FTE) physicians3 in 2000 to 971,800 in 2020, a 24 

percent increase. However, growth is expected to 

slow considerably after 2010, reflecting increased 

rates of physician separation due to the aging of 

the current physician workforce and the relatively 

level annual number of new physician entrants since 

1980. After 2015, the rate of population growth 

will exceed the rate of growth in the number of 

physicians. The per capita number of physicians is 

forecasted to rise from 283 per 100,000 Americans 

in 2000 to 301 in 2015 but then drop to 298 in 

2020. Under alternative assumptions regarding 

physician lifestyle changes (such as hours worked) 

and increased productivity, the effective supply of 

physicians (FTEs) may grow to nearly 1.08 million 

physicians in 2020. The most probable aggregate 

projection suggests that the supply of physicians will 

number approximately 1.02 million FTEs in 2020.

2. At the same time, for a number of reasons and under 

a number of scenarios and models, the demand

for physicians is likely to grow even more rapidly 

over this period than the supply. It is likely that 

the demand for physician services will grow to 

between 1.03 million and 1.24 million physicians in 

2020. The three major factors driving the increase 

in demand will be: a) the projected U.S. population 

growth of 50 million persons (18 percent) between 

2000 and 2020; b) the aging of the population, as 

the number of Americans over 65 increases from 

35 million in 2000 to 54 million in 2020; and c) 

the changing age-specific per capita physician 

utilization rates, with those under age 45 using fewer 

services and those over age 45 using more services.

3. The need for services, reflecting primarily the use 

of services under universal insurance and increased 

utilization review processes, is also expected to 

increase over the period. Need is projected to grow 

to between 1.09 and 1.17 million physicians in 2020
SIXTEENTH REPORT OF COGME xvi 

4. If the Nation’s population continues to use services in the future as it has in the past, and if 

physicians practice in the future as they have 

in the past, then the Nation is likely to face a 

shortage of physicians in the coming years.

a. When the midpoint of the projected range 

of future supply and demand is used, the 

Nation is projected to face a shortage 

of about 85,000 physicians in 2020.

b. When the midpoint of the projected 

range of supply and need is used, the 

Nation is projected to face a shortage 

of about 96,000 physicians in 2020.

5. The models and alternative scenarios used to 

make the predictions included a number of factors that could have a major impact on supply, demand, and need and, consequently, 

on a potential gap in the physician supply.

a. Many of these factors are likely to add 

to the shortage of physicians. Some of 

these have been included in the report 

as scenarios that could have an impact 

on the supply or demand for physicians. These include the following:

Ø Changing lifestyles for 

the newest generation of 

physicians, with the possibility 

that new physicians will 

work fewer hours than their 

predecessors; 

Ø Continuation of the rate of 

increase in the use of physician 

services by those over 45, 

which has been increasing 

for the past 20 years, and 

increased use of services by 

the baby-boom generation 

compared to prior generations; 

and

Ø Expected increases in the 

Nation’s wealth that would 

contribute to continued 

increases in the use of medical 

services.

Other factors could also lead to larger 

shortages and are not included in the 

baseline projections or alternative 

scenarios. These include the following:

Ø A potential increase in nonpatient care activities by 

physicians, including research 

and administrative activities; 

Ø A potential change in practice 

patterns for physicians over 50, 

including a reduction in hours 

worked before retirement and 

earlier retirement patterns; 

Ø Possible increases in

departures from practice 

due to liability concerns of 

physicians; 

Ø Decreases in hours worked by 

physicians in training; 

Ø Possible decreases in 

immigration of graduates of 

foreign medical schools; 

Ø Possible increases in the 

number of physicians limiting 

the number of patients on their 

panel (sometimes referred to as 

“boutique medicine”); 

Ø Advances in genetic testing 

that could lead to increases 

in the use of services as 

individuals learn they are at 

risk for certain illnesses or 

conditions; and 

Ø Additional medical advances 

likely to keep individuals with 

chronic illnesses alive longer 

without curing their illnesses.

b. A number of factors also may limit future shortages. These include factors 

for which estimates of their impact are 

presented in the report under different 

scenarios. These include the following:

Ø Increases in productivity, 

such as through improved 

technologies and information 

systems; and

Ø More effective utilization 

review and quality assurance 

efforts to weed out 

inappropriate or unnecessary 

services.
SIXTEENTH REPORT OF COGME xvii

Other factors not included in the 

supply, demand, and need projections with the potential to reduce projected shortages include the following:

Ø Increases in the supply and use of 

nurse practitioners, physician 

assistants, and other non-physician clinicians;

Ø Increases in costs and cost 

sharing; and 

Ø Medical breakthroughs that 

decrease service use.

6. There are already a growing number of reports of, 

and concerns with, shortages in specific specialties. These include such specialties as radiology 

(Sunshine 2001), anesthesiology (Schubert et al 

2001; Miller and Lanier 2001; Schubert et al 2003), 

cardiology (Foot et al 2000), rheumatology (Boyce 

2003), nephrology (Neilson et al 2001), pulmonary 

disease/critical care (Angus et al 2000; Pronovost 

et al 2002), and child psychiatry (Kim et al 2001).

7. Although the percentage of the Nation’s physicians 

who are generalists has increased slightly over 

the past decade, it is currently about 38 percent, 

well below the 50 percent target recommended in 

COGME’s Third Report. Even in the Kaiser Health 

Plans, only about 40 percent of their physicians in 

2001 and 2002 (Weiner 2004) were generalists. Results of surveys of new physicians completing training in New York and California indicate that demand 

for generalists is less than demand for most nongeneralists, further weakening the case for the 50 

percent generalist goal (Nolan et al 2003a, 2003b).

RECOMMENDATIONS

Preamble

The State of the Nation’s health care workforce 

directly affects both the health of the American public 

and the economics of health care. It is not our intent 

to codify or explicitly endorse the current health care 

system. Given the constraints and confines of the 

available data, these recommendations are a feasible 

and realistic approach to physician workforce planning.

In light of the likely gap between the expected supply, 

demand, and need for physicians in the future, COGME 

recommends that the Nation undertake a multi-pronged 

strategy that includes: a modest increase in medical 

education and training capacity over the next decade; efforts 

to increase physician productivity; and increased tracking 

and assessments of the supply, demand, and need for 

physicians. In addition, because underserved communities 

are most likely to be affected by shortages, COGME 

recommends that the National Health Service Corps (NHSC) 

and other Federal programs designed to address geographic 

and specialty maldistribution and to increase diversity be 

expanded. Specific recommendations are presented below.

1. To meet the future physician workforce demand 

and need in the U.S., COGME recommends that:

a. The number of physicians entering 

residency training each year be increased 

from approximately 24,000 in 2002 to 

27,000 in 2015; and 

b. The distribution between generalists and 

non-generalists should reflect ongoing 

assessments of demand; therefore, 

COGME does not recommend a rigid 

national numerical target.

The analysis presented in this report indicates that the 

Nation is likely to be facing a shortage of physicians in the 

coming years, particularly in non-generalist specialties. To 

begin to address this likely shortage, COGME recommends 

that the total number of physicians entering residency training in the U.S. be increased to 27,000 per year over the next 

decade. This action would lead to an increase in the Nation’s 

physician workforce by about 3 percent (30,000 physicians) 

by 2020. Although this level of new entrants into medicine 

will be insufficient to meet future needs, it is an important step.

This physician workforce goal is presented as an absolute number rather than as a percentage of the number of U.S. 

medical graduates in a specific year. This absolute number 

is easier to understand and track, and therefore should be 

a more useful target for the Nation. When presented as a 

percentage of medical school graduates, the recommended 

number of entrants into residency training is equal to 158 

percent of the number of 1993 U.S. medical graduates and 

150 percent of the 2000 U.S. medical school graduates.

Currently, approximately 37 percent of new physicians 

are entering generalist specialties, and 63 percent are entering 

non-generalist specialties. COGME recommends below that 

the Nation undertake studies to track overall specialty-specific need, demand, and distribution and to share this information with the medical education and training community. 

Specialty-specific need and demand for physicians are likely 

to vary over time and by region. Therefore, a single national 

goal is inappropriate. Physicians should be encouraged to select specific specialties with shortages. This selection could 

be facilitated by providing physicians information on practice 

opportunities by specialties and, where appropriate, should be 

offered such fiscal incentives as loan repayment opportunities.

2. Increase total enrollment in U.S. medical schools 

by 15 percent from their 2002 levels over the next 

decade.
SIXTEENTH REPORT OF COGME xviii 

To assure reasonable access to care for Americans in 

coming years, COGME recommends that total U.S. allopathic and osteopathic medical school enrollment be increased by 

15 percent by 2015. This step will require a combination of 

increased enrollment at existing medical schools and, potentially, the establishment of a number of new medical schools.

A modest increase in medical school enrollment over the 

next decade will have only a limited impact on the total supply 

of physicians in 2020 but would provide a base for responding 

to future needs. Decisions on medical school capacity need 

to be made now if the Nation is going to be able to produce 

more U.S. medical school graduates in 2015 and beyond.

Between 1982 and 2001, the number of medical 

students in the U.S. increased 7 percent while the U.S. 

population grew 23 percent, leading to a 13 percent net 

decrease in medical school students per capita in the U.S. 

Between 2000 and 2020, the U.S. population is projected 

to increase by 18 percent while medical school capacity is 

scheduled to increase by only about 4 percent, leading to a 

further decrease in per capita medical students. The recommended 15 percent increase would still leave the number 

of medical students per capita well below the 1980 level.

If the actual shortage is not as significant as predicted in this report, the modest increase of about 3,000 

new U.S. graduates per year by 2015 would allow the 

U.S. to reduce its current reliance on the approximately 

5,200 international medical school graduates (IMGs) who 

enter residency training each year. This policy would 

be consistent with those advocated by many observers 

(Mullan 2000). Most IMGs come from countries that 

have far fewer physicians per capita than the U.S. has.

Given the uncertainty inherent in long-term forecasting of 

supply, demand, and need, and the cost of a major expansion 

in medical school capacity, COGME does not recommend 

that the Nation attempt to address all the possible shortages 

through a dramatic increase in medical education capacity at 

the present time. Rather, COGME recommends that the medical education community increase enrollment moderately now 

and that the Nation take other steps that have the potential to 

reduce future shortages. Although it may be necessary to increase enrollment more than 15 percent in the coming years, 

the decision should be made based on further study over the 

next few years, as discussed in recommendation five below.

At this time, the Council is not recommending a new 

Federal program to encourage new medical schools or 

increased enrollment at existing medical schools. It is 

hoped that the medical education community and States 

will respond to the recommendations in this report and to 

the growing evidence of unmet physician workforce needs.

3. Phase in an increase in the number of residency 

and fellowship positions eligible for funding 

from Medicare to parallel the increase in U.S. 

medical school graduates recommended above.

Over the next decade, teaching hospitals will need to increase the number of training positions to accommodate the 

increasing number of U.S. medical school graduates. The 

current cap on the number of residents and fellows eligible 

for Medicare reimbursement strongly discourages teaching hospitals from increasing the number of residents. To 

encourage a modest increase in residents, COGME recommends that the cap be increased slowly over the next decade.

The current cap was intended to discourage increases 

in the number of physicians trained in the U.S. It was conceived and approved when there was a period of concern 

with potential surpluses of physicians and when it appeared 

that managed care would reduce the use of health care services. As the Nation now looks at its physician needs for 

2015 and beyond, the far greater likelihood is a physician 

shortage. The Medicare policy should be adjusted to help 

meet future physician needs that will be driven in large 

part by the growing number of elderly covered by the 

Medicare program. In light of the growth in graduates of 

osteopathic schools over the past decade and the increasing number of entrants to allopathic schools, it is important to begin to increase the GME cap as soon as possible.

4. Develop systems to track the supply, demand, need, and distribution of physicians, 

and undertake a comprehensive re-assessment within the next 4 years to guide future 

decisions on medical education capacity.

Given the costs of increasing medical education and 

training capacity and the uncertainty inherent in any effort 

to forecast physician workforce many years into the future, 

it is strongly recommended that the Nation develop systems 

to track physician workforce supply, demand, need, and 

distribution on a regular and consistent basis. This recommendation is especially important in light of the many 

years needed to make changes in the supply of physicians.

In addition to ongoing tracking, COGME recommends 

that the Nation undertake a comprehensive re-assessment 

within the next 4 years that would consider the many factors 

that could have an impact on the physician workforce in the 

future in greater depth than the current re-assessment. Major 

industries, especially those in which changes in production 

require both substantial investments and many years to 

implement, exemplify this point. The leaders in these industries recognize the critical role of regular assessments of the 

current and future marketplace. The current study considers 

available data, but important gaps exist in these data as well as 

in our understanding of physician practice patterns. In addition, some information (e.g., retirement patterns of the babyboom generation of physicians) cannot be known at this time.
SIXTEENTH REPORT OF COGME xix

5. Additional specialty-specific studies are 

needed to better understand the physician 

workforce needs and to inform the medical education community and policy makers of the Nation’s specialty-specific needs.

On the basis of available data, the Nation appears to have 

a ratio of 38 percent generalist specialties and 62 percent nongeneralist specialties. This greater demand for non-generalist 

specialties is borne out by surveys of new physicians completing residency training in the U.S. and the growing number 

of reports of shortages in non-generalist specialties (Schubert 

et al 2003; Miller and Lanier 2001; Schubert et al 2001; Foot 

et al 2000; Kim et al 2001; Suneja et al 2001; Neilson et 

al 2001; Angus et al 2000; Pronovost et al 2002; Sunshine 

2001; Organ 2002; Etzoni et al 2003; Fleming et al 2003).

Experience over the past decade has demonstrated 

that medical students, physicians in training, residency 

programs, and teaching hospitals respond to marketplace 

signals on supply and demand for different specialties. Unfortunately, specialty-specific studies have been conducted 

only sporadically in the past and often used questionable 

research methods and data. The Federal Government 

should take a leadership role in developing and encouraging common methodologies for specialty-specific studies.

Providing the medical education community and policy 

makers with better information on current and future needs 

and on gaps in physician supply by specialty should contribute to a specialty mix more consistent with national needs. 

Accurate and timely information and data are a prerequisite 

for an effective market of any type. This information should 

help guide Federal policies related to the physician workforce.

6. Promote efforts to increase the productivity of 

physicians.

The Nation should consider several steps to promote 

productivity improvements. These steps include:

Ø Funding to evaluate the effectiveness and

 efficiency of alternative models of care, and

 practice and organizational arrangements;

Ø Evaluation of specific new technologies;

Ø Dissemination of information to physicians

 on the effectiveness of alternative models of

 care, new technologies, and other strategies to

 improve productivity; and

Ø Introduction of reimbursement policies to

 support implementation of productivity

 enhancements.

A modest annual rate of increase in physician productivity would have a major long-term impact on the number of 

new physicians needed by the Nation. These steps could also 

encourage physicians to practice longer rather than retire or 

leave medical practice, thus effectively increasing the supply 

of physicians.

New technologies and improvements in existing 

technologies have the potential to increase productivity, 

improve quality, and increase physician satisfaction. Particularly promising is the potential for the electronic medical record and other advances in information technology. 

These advances have the potential to increase efficiency 

and effectiveness, to reduce the time needed for documentation, and to speed the retrieval of needed information. 

Remote patient monitoring systems, telecommunications 

advances, and Internet access to the latest medical knowledge and technologies have the potential to increase the 

number of patients who can be cared for by a physician.

There are a number of barriers to the expansion of 

effective new technologies. First, many of these technologies require an enormous investment to develop and 

acquire. Second, many new technologies are still to be 

perfected and are evolving rapidly, leading to appropriate caution on the part of physicians and the organizations that use them. A third barrier for certain types of 

technologies is reimbursement policies. For example, if 

insurers do not cover group sessions or interactions between physician and patient over the Internet, then these 

approaches will be less attractive to physicians and patients.

7. Expand programs and develop policies that:

Ø Address geographic maldistribution of 

physicians,

Ø Improve access to care for underserved 

populations and communities,

Ø Promote appropriate specialty distribution 

and deployment,

Ø Promote workforce diversity, and

Ø Support analyses of data related to these 

issues.

The projected shortage of physicians is likely to have the 

greatest impact on underserved and poorer communities that 

have historically had the greatest difficulty recruiting and retaining physicians. To assure access for our most needy citizens, it will be important to maintain and expand programs 

that support access to physician services by underserved 

populations. In anticipation of future shortages, the number 

of scholarship and loan repayment awards under the NHSC 

should be increased.
SIXTEENTH REPORT OF COGME xx 

As indicated in this report, shortages for non-generalists are likely. Although generalists play a central role in 

underserved communities, these communities also require 

access to non-generalists. Therefore, COGME recommends that the NHSC be expanded to include non-generalist 

specialties. These awards should be targeted to specialties 

with documented shortages in underserved communities. 

Giving underserved communities access to non-generalists 

should be accomplished while maintaining an emphasis on 

access to primary care services. By identifying specialties 

experiencing shortages for purposes of the NHSC program, 

the Federal Government would also send an important 

message to medical students about specialties in need.

Title VII of the Public Health Service Act includes 

programs specifically designed to encourage practice in 

rural and other underserved areas, to increase the diversity of the workforce, to promote more effective medical 

and interdisciplinary education, and to collect and analyze 

workforce data. These programs play a critical role in helping assure access to needed services and will be particularly 

important in a period of physician shortage. COGME recommends that these programs receive continued support.

In addition to physician workforce programs that 

directly address needs in health care delivery, policy 

exerts its influence through reimbursement and regulatory actions. For example, direct and indirect GME payments through Medicare, as well as differential payments 

for health care services, have an influence on training 

opportunities, medical specialty choices, and career location 

decisions. These influences should be evaluated, understood, 

and more closely aligned with health care policy goals.

RELATED ISSUES OF CONCERN

Distribution of Physicians: This analysis assesses the 

total number of physicians across the country and does not 

assess supply, demand, or need by State, region, or locality. 

It is possible for the Nation to have enough or even more 

than enough physicians in aggregate and still have significant shortages in specific communities. Although having an 

adequate supply nationally will make it easier to address distribution issues, increasing the supply will not in and of itself 

address issues of maldistribution of physicians. Although 

this issue is not the focus of this report, it is an issue of great 

importance to the Nation and to COGME. Given the shortages predicted in this report, it is likely that currently underserved areas will face greater shortages in coming years if 

steps are not taken to ameliorate the overall physician supply 

shortage. The Council intends to undertake a review of programs and strategies to address the distribution of physicians 

and to make recommendations in a future report for better 

assuring an adequate distribution of the physician workforce.

U.S. Medical School Graduates and International 

Medical School Graduates (IMGs): There are two major 

sources of new physicians in America: graduates of U.S. 

medical schools and graduates of non-U.S. medical schools. 

The Nation could address the predicted future shortage by 

increasing the number of physicians from one or both of 

these sources. This report neither recommends an increase in 

the number of IMGs entering residency training as a way to 

address future shortages, nor recommends a decrease in the 

number of IMGs entering the U.S. It is not the purpose of 

this report to assess the pros and cons of using IMGs to meet 

physician workforce needs in the U.S., but it is recognized 

that the issues of IMG policies, U.S. medical school capacity, and the total number of physicians produced in the U.S. 

are interrelated. Clearly, if a decision were made to reduce 

the reliance on IMGs, it would be necessary to increase U.S. 

medical school enrollment more than recommended above 

to achieve the goal of 27,000 new entrants in 2015. Conversely, an increase in the number of IMGs entering the U.S. 

would reduce the need for more U.S. medical graduates.

Impact of Reimbursement Policies on Demand for Physician Services: Undoubtedly, the demand for a specialty or 

group of specialties is affected by reimbursement policies. 

Low levels of reimbursement for services can depress demand below need. The models used in the current reassessment of supply, demand, and need rely heavily on historical 

patterns of use that have been influenced by reimbursement 

policies. Results of recent surveys of residents completing 

training in California and New York show that the incomes 

of non-generalists are significantly higher than the income of 

generalists and that the gap is growing (Nolan et al 2003a, 

2003b, 2003c). Although the imbalance between the income 

of generalist and non-generalist physicians is not the focus of 

this report, it probably affects the measurement of demand 

and need. It may be appropriate to reassess the relative 

levels of reimbursement of generalists and non-generalists 

under current reimbursement systems, including Medicare.

Unnecessary Services: Some research findings suggest that some services provided by physicians may be of 

marginal benefit or even unnecessary (Weiner 1994, 1995, 

2004; Fisher et al 2003a, 2003b). Drawing on recent research on staffing ratios in prepaid group practices and the 

relationship between health status and aggregate physician 

service utilization, the report presents what the impact 

would be on demand and need if some process were found 

to identify and eliminate unnecessary or ineffective services.

Some have suggested that the number of physicians 

educated and trained in the U.S. should take this into account (i.e., the Nation should produce fewer physicians 

because some services are unnecessary). However, in the 

absence of programs and policies that effectively identify and eliminate the unnecessary or inappropriate services, 

constraining supply is likely to lead to even greater shortages and delays in access to services for the public at large. 

Such shortages and delays might occur especially in underserved communities and among vulnerable populations.
SIXTEENTH REPORT OF COGME 1

 

Background

The Council on Graduate Medical Education (COGME) 

was authorized by Congress in 1986 to assess physician workforce trends, training issues, and financing policies, as well as 

to recommend appropriate Federal and private-sector efforts 

to address identified needs. One of the most important physician workforce issues for COGME and the Nation is the assessment of the number, specialty, and geographical distribution of physicians that would need to be educated and trained 

to assure access to quality care for Americans. For the last 

decade, a series of physician workforce policy goals held by 

COGME have centered around its “110/50-50” recommendations. These goals and recommendations should be revised.

First articulated in its Third Report, Improving Access to 

Health Care Through Physician Workforce Reform: Directions for the 21st Century (1992), the 110/50-50 recommendations called for reducing the number of physicians entering 

residency training from what was then 140 percent to 110 

percent of the number of graduates from allopathic and osteopathic medical schools in the U.S. in 1993. Conceptually, 

the 110 percent would be sufficient to ensure that all U.S. 

medical school graduates would be able to enter graduate 

medical training, as well as IMGs equal in number to 10 

percent of the U.S. graduates. The Third Report called for 

increasing the percentage of graduates who complete training and enter practice as generalists from the level then at 

30 percent to at least 50 percent. COGME’s Eighth Report, 

Patient Care Physician Supply and Requirements: Testing 

COGME Recommendations (1996), provided underlying 

physician supply and requirements projections that tended 

to support the reasonableness of the recommendations. 

COGME’s Fourteenth Report, COGME Physician Workforce Policies: Recent Developments and Remaining Challenges in Meeting National Goals (1999), in calculating the 

progress made toward the COGME goals, found that as of 

1997 and 1998, the Nation’s first-year residents amounted 

to approximately 129 percent of the number of graduates 

from allopathic and osteopathic medical schools in the U.S. 

in 1993. This report also found that it would be necessary 

to reduce the number of first-year residents by about 3,400 

to reach the 110 percent goal set by COGME in 1992.

The Fourteenth Report identified several recent developments that were likely to affect the supply or demand, or 

both, for physician services. These developments include: 

the evolving nature of managed care, the growing supply 

of non-physician clinicians, and the growing representation 

of women in medicine. In this 1999 report, the Council 

stated its intention of re-assessing the appropriateness of its 

110/50-50 recommendations in light of recent developments.
SIXTEENTH REPORT OF COGME 2 
SIXTEENTH REPORT OF COGME 3

Supply of Physicians, 2000-2020

OVERVIEW OF METHODOLOGY: 

BASELINE MODEL AND FACTORS 

AFFECTING FUTURE SUPPLY

The forecast of physician supply in the U.S. between 

2000 and 2020 is based on the Physician Supply Model 

(PSM). This model, developed and maintained by the 

Bureau of Health Professions (BHPr), HRSA, DHHS, 

produces projections of the supply of physicians by type 

(Medical Doctor [MD] and Doctor of Osteopathy [DO]) 

and specialty for 1995 through 2040. For the purposes of 

this report, the years of interest are 2000 through 2020, and 

the specialty groups of interest are generalists and nongeneralists. This section presents the total supply forecasts 

and factors affecting the overall supply of physicians in the 

U.S. Projections for generalists and non-generalists appear in Section V, “Physician Supply, Demand, and Need.”

The unit of analysis for the assessment is a full-time 

equivalent (FTE) active physician. This unit includes all 

physicians active in medicine, regardless of whether they 

are providing patient care. It is estimated that about 6 

percent of active physicians in 2000 were not providing 

patient care. Many of these physicians were involved in 

teaching, administration, and research (Pasko and Seidman 

2002). Since one goal of the project is to assess the number of physicians that would need to be produced to meet 

future needs, it is necessary to include non-patient care 

physicians as well as active physicians in the projections. 

To take into account the fact that some physicians practice 

less than full-time, for this analysis, supply, demand, and 

need are calculated in terms of full-time equivalents; that 

is, two physicians working half-time are equal to one FTE.

The calculation of future physician supply begins 

with the number of physicians entering residency training. The methodology includes the following steps:

1. The PSM begins with the active base year physicians 

by type and post-medical school graduate year (PGY).

For each forecast year:

2. The base year physicians are aged, and agespecific death and retirement rates are applied.

3. The physicians are summed over all ages to 

calculate the base physicians by type and PGY.

4. Specialty distributions are applied by type and PGY.

5. Activity distributions are applied by type, specialty, 

and PGY.

6. New entrants by year (2001 through 

2020) of each type of physician indicated 

below, using the data described, are tallied:

 United States Medical School Graduates 

(USMGs): New graduates from U.S. medical 

schools and percentage of females by year;

 Canadian Medical School Graduates (CMGs): 

New graduates from Canadian medical 

schools and percentage of females by year;

 IMGs: International medical school graduates 

who are GME entrants and percentage of 

females by year; IMGs who are non-GME 

entrants and percentage of females by year;

7. New entrants are aged over the period 2000 through 

2020 for each and the appropriate age and typespecific death and retirement rates are applied;

8. Specialty distributions are those applied 

by type and PGY to new entrants;

9. Activity distributions are those applied by 

type, specialty, and PGY to new entrants;

10. Forecasts of base year physicians and new 

entrant physicians by type, PGY, specialty, 

and activity are summed over PGY to 

produce final forecasts (Bannister et al 2001).

The forecast totals are then converted to FTEs. Table 1 presents the results of the baseline supply model.

The supply of physicians is projected to grow by 

some 190,000 FTEs (24 percent) between 2000 and 

2020.4 Over the same time period, the U.S. Census Bureau projects an 18 percent growth in the U.S. population, 

yielding a net 5 percent growth in the physician-to-population ratio. As indicated in Table 1, the supply expressed 

as FTEs per capita peaks around 2015, and then begins 

to fall, as the rate of population growth begins to outstrip the rate of growth in the supply of physician FTEs.

4

 It should be noted that data for the base year 2000 for the supply projections were unavailable before the current analysis. Thus, comparisons with other 

projections based on the PSM that used 1995 data as the base year are inappropriate. Projections using 1995 base year data yield supply projections lower 

than the actual supply between 1996 and 2000. Currently, the PSM is being updated to a more recent base year. These updates were unavailable to the 

authors during the period this report was developed.
SIXTEENTH REPORT OF COGME 4 

The data used in the PSM for this project were derived 

from the following sources:

 Current supply and characteristics:

o American Medical Association (AMA) 

Physician Masterfile

o American Osteopathic Association (AOA) 

Masterfile

 Distribution by age, gender, and IMG status: AMA 

Physician Masterfile

 New U.S. graduates 2000 by age and gender: 

Association of American Medical Colleges 

(AAMC), AMA, and AOA Masterfile

 New CMGs and IMGs: AMA Graduate Medical 

Education data

 Retirements, deaths, and departures: Analysis of 

AMA Physician Masterfile patterns 1990 through 

1995

Given this methodology, it is clear that the 

model takes a number of basic factors into account in making projections. These factors include:

1. The overall number of new entrants into the 

physician workforce and the source of the new 

entrants (i.e., U.S. medical schools or abroad);

2. The gender distribution of the current 

physician supply and of new entrants and its 

effect on the relative number of hours spent 

in professional activities (to calculate FTEs);

3. The age distribution of the current physician supply;

4. Retirement, death, and other separation rates of the 

current physician supply;

TABLE 1

Supply of Physicians in the U.S., 2000-2020:

Baseline Projections

Year

FTE

Physicians

U.S. 

Population

(1,000s)

FTEs per

100k Pop.

2000 781,227 276,241 283

2005 844,464 288,286 293

2010 899,540 300,431 299

2015 942,145 313,116 301

2020 971,817 325,942 298

% Change 24% 18% 5%

5. The specialty distribution of the current physician 

supply and the specialty choices of new entrants; and

6. The rates of different types of professional 

activities (e.g., patient care, teaching, and 

research) of the current physician supply.

These factors are included in the supply projection 

model through the use of historical rates and trends derived 

from both previous research and the data sources listed 

above. Below, these factors are discussed in more detail, and 

any assumptions made in the baseline model are revealed.

New Entrants

Number of U.S. medical school graduates: The 

baseline model assumes that the number of U.S. allopathic 

medical school graduates will remain essentially constant 

through 2020 at 16,000 per year. It also assumes that osteopathic graduates will continue to increase from about 2,300 

in 2000 to 3,000 in 2009, and then stabilize at that level. It 

further assumes that the number of Canadian entrants into 

the U.S. health system will slowly rise from 191 in 2000 

to 247 in 2020. Thus, for most of the period, it is assumed 

that there will be about 19,000 new USMG, CMG, and DO 

entrants each year. Table 2 presents the estimated entrants 

into the health care system between 2000 and 2020 as used 

in the model. Figure 1 shows the number of allopathic and 

osteopathic graduates over the past 20 years and the forecast 

for 2001 through 2020. Figure 2 depicts the extent to which 

the growth of the U.S. population has exceeded the growth 

in the number of students enrolled in U.S. medical schools.

The medical school community has discussed the possibility of new medical schools and increases in enrollment 

at existing medical schools (e.g., see Cooper 2003; Mullan 

2003; Wood 2003; Hallock et al 2003; as well as Mullan 

2000). Several new schools are in various stages of development or accreditation (e.g., in Florida, Arizona, and Texas). 
SIXTEENTH REPORT OF COGME 5

TABLE 2

Projected Number of New Entrants 

Into the Physician Supply, 2000-2020

Year

USMG

Entrants

CMG

Entrants

DO

Entrants

IMG

Entrants

2000 15,824 191 2,304 5,200

2005 16,000 219 2,650 5,200

2010 16,000 230 3,000 5,200

2015 16,000 245 3,000 5,200

2020 16,000 247 3,000 5,200

% Change 1% 29% 30% 0%

FIGURE 1

Total Number of Allopathic and Osteopathic Graduates, 1980-2020

Data for 1980-2000 are taken from: American Association of Colleges of Osteopathic Medicine, 2000 Annual Statistical Report; Association of American Medical Colleges, AAMC Data Book. Data beyond 2000 are projections 

based on the projections used in the baseline supply model.
SIXTEENTH REPORT OF COGME 6 

FIGURE 2

Change in Medical Students, Population, and Students 

per Population, 1980-2020

Source: American Association of Colleges of Osteopathic Medicine, Annual Statistical Report 2000; Association of 

American Medical Colleges, AAMC Data Book; U.S. Census Bureau.

Several additional new schools are being discussed in other 

locations, but this development is likely to add only a modest 

number of new physicians to the supply over the next several 

years. This is the case because of the time it takes before 

new medical schools produce practicing physicians, as well 

as the modest nature of current development efforts. This 

expansion is not factored into any models described in this 

analysis. Moreover, several other important issues related to 

the expansion of medical education in the U.S. would have to 

be addressed before any large-scale expansion could occur.

Number of international medical school graduates: The baseline model assumes 5,200 new IMG entrants 

per year based on historical trends. An analysis of AMA 

GME data and the AMA Physician Masterfile indicates 

that this is close to the experience throughout the 1990s. 

Given recent political developments (i.e., the tragic events 

of September 11, 2001; increased scrutiny of immigrants 

domestically; Operation Iraqi Freedom; as well as a host 

of others), it is possible that future immigration policies 

will limit the flow of IMGs into the U.S. in coming years.

It is certainly conceivable that the current inflow 

could decrease in the near future. Any decrease in the 

number of IMGs entering the physician supply without 

a simultaneous increase of USMG, CMG, and DO entrants would lead to fewer physicians than are currently 

projected. At the same time, it is also conceivable that 

the number of IMGs could increase because of the recent 

upswing in U.S. citizens attending medical schools abroad 

(Salsberg and Forte 2002). These potential changes are 

not factored into any models described in this analysis.

Women in Medicine

Women have made great strides in medicine over 

the past 20 years, nearly tripling their representation 

in the profession. Currently making up about 25 percent of the physician workforce, women will continue 

to become a larger part of the workforce because they 

currently make up nearly 50 percent of the students enrolled in U.S. medical schools (Salsberg and Forte 2002).

A number of studies have documented that women 

work fewer hours over the course of their professional 

work life than men (Kletke, Marder, and Silberger 1990; 

Bobula 1980; Martin et al 1988; Cooper 1994; Australian 

Medical Workforce Advisory Committee/Australian Institute of Health and Welfare [AMWAC/AHIW] 1996, 1998; 
SIXTEENTH REPORT OF COGME 7

Sullivan and Buske 1998; Forte and Salsberg 1999). This 

phenomenon may reflect time taken for child rearing, for 

providing care for elderly parents or other relatives, and 

for taking care of other family concerns. The baseline 

model accounts for the gender difference as it is based 

on historical work patterns. As Table 3 shows, the FTEto-physician ratio decreases over time. This decrease is 

indicative of the increasing representation of women in the 

physician workforce as well as the aging of the workforce.

Aging of the Physician Workforce

Like the rest of the U.S. population, physicians, as a 

group, are growing older. In fact, between 1982 and 2001, 

the proportion of physicians aged 65 and older increased 

from 8 percent to 11 percent. In 2001, more than 84,000 

practicing physicians were 65 years of age or older, another 

118,000 between 55 and 64 will reach 65 by 2011, and another 203,000 between 45 and 54 will reach 65 by 2021 (Figure 

3). The baseline model accounts for these changes by applying historical age-specific activity rates to the supply of physicians each year, as well as by adjusting for this in the FTEto-physician ratios used to calculate FTEs. If these activity 

rates do change in the future, the projections of the baseline 

model will either under- or overestimate the actual supply 

of physicians depending on the direction of the change.

Separation From the Physician 

Workforce

In some ways, separation from the physician workforce 

is related to age. As a physician ages, he is more likely to 

leave practice for one reason or another, for example, retirement or death. The baseline model assumes that physicians 

in the future will separate from the workforce at the same 

age-specific rates as they have historically. In other words, 

physicians in the future will time their retirements as physicians have in the past. With the aging of the physician 

population, a larger and larger proportion of the physician 

workforce will be reaching the traditional age of retirement in 

TABLE 3

FTE-to-Physician Ratio, 2000-2020

Year Generalist

NonGeneralist Overall

2000 0.997 0.995 0.996

2005 0.994 0.992 0.993

2010 0.988 0.985 0.986

2015 0.981 0.979 0.980

2020 0.976 0.975 0.976

% Change –2% –2% –2%

the near future. This larger proportion is reflected in the baseline model by an increase in the net retirement rate from 1.2 

percent in 2000 to 1.9 percent in 2019, a 58 percent increase.

There is no way to know with certainty the actual retirement patterns of physicians in future years. Earlier retirement of the baby-boom generation of physicians than of 

previous generations would significantly reduce the supply 

of physicians in 2020. On the other hand, if physicians are 

working fewer hours per week because of changing lifestyle choices, they may stay in practice for a longer period 

of time, not having as much chance to burn out or become 

dissatisfied for some other reason. This phenomenon might 

lead to an increase in the supply of physicians in 2020.

In addition, since there is no reason to expect the other sources of separation (e.g., death) to 

change, they are also held at their historical levels.

Specialty Distribution and Choices

The issue of specialty distribution and choice has less to 

do with the overall supply of physicians than with the types 

of services provided by physicians. The specific specialty a 

physician practices has implications for the types of services 

provided. As mentioned previously, for the purposes of this 

re-assessment, discussion and consideration of specialty were 

limited to a generalist and non-generalist distinction. The 

baseline model assumes that physicians will choose specialties according to their historical patterns of specialty choice; 

that is, about 68 percent of physicians will eventually practice 

in non-generalist specialties. The model also assumes that 

physicians will have made their final specialty choices by the 

tenth year after the start of their graduate medical training.

There have been a number of attempts at understanding the reasons behind physicians’ specialty choices (Hay 

1991; Hurley 1991; Nicholson 2002; Puccio et al 2002; 

Newton and Grayson 2003; Dorsey et al 2003). The factors most often cited to explain variation in specialty choice 

include expected income, intellectual content of the specialty, research opportunities in the specialty, prestige of the 

specialty, gender and race/ethnicity of the physician, family considerations, and others. The dynamics of specialty 

choice are beyond the scope of this re-assessment. Thus, 

as noted above, unless otherwise stated, historical rates of 

specialty choice by age and location of education (USMG 

or IMG) are employed in the models presented in this paper.

Activity Rates

Being a physician involves a variety of activities, including patient care, medical teaching, medical research, 

and other medical activities. Physicians, however, are not 

limited to those types of activities. The rate at which the 

supply of physicians in the Nation participates in activities 
SIXTEENTH REPORT OF COGME 8 

FIGURE 3

Age Distribution of Active Allopathic Physicians in the U.S., 1982 and 2001

Sources: Eiler M. Physician Characteristics and Distribution in the U.S. 1983 Edition. American Medical Association; 

Pasko and Smart. Physician Characteristics and Distribution in the U.S. 2003-2004 Edition. American Medical Association.

within their field of expertise (i.e., medicine) and activities 

outside the realm of medicine directly affects the number of 

available physicians. The baseline model assumes that activity rates will remain at their historical levels. If activities 

outside the scope of what are currently considered the professional activities of a physician (e.g., physicians working as 

financial analysts) become more attractive to physicians, the 

effective supply of physicians in the U.S. would decrease.

Moreover, changes in the distribution of activities in 

which a physician participates could also have effects on the 

supply of physicians. For example, the average physician 

typically spends the most amount of her time in patient care. 

If more physicians devoted more time to research, the supply 

of physicians providing patient care services would decrease. 

Dynamics within the professional activities of physicians 

are beyond the scope of this re-assessment. In fact, since 

the models project active physicians, distinctions between 

types of professional activity are not taken into account. 

Again, such distinctions only become important if there 

is an increase in the rate of participation in an activity that 

is associated with significantly different practice patterns.

ALTERNATIVE SUPPLY SCENARIOS 

AND ASSUMPTIONS

The baseline models used in this report are based on 

historical data. A number of other scenarios were modeled 

and sensitivity analyses performed to assess the impact of 

potential changes in key factors influencing the supply of 

physicians. Each alternative scenario was built to represent 

the impact of changes to one key factor affecting the future 

supply of physicians in the U.S., or two factors in the case 

of hybrid models. The scenarios developed for this report 

are only a sampling of the myriad possibilities that could 

occur over the next two decades in the physician workforce. 

The following discussion presents the background and 

the results of the projections generated for each scenario.

Alternative Scenario One: 

Lifestyle Changes

A number of observers of the physician workforce have 

noted the desire of many, or even most, new physicians to 

balance professional and personal activities, i.e., to have a 
SIXTEENTH REPORT OF COGME 9

more controllable lifestyle (Schwartz et al 1989; Schwartz 

et al 1990; Jarecky et al 1991; Bland and Isaacs, 2002; 

Gelfand et al 2002). These observers have also noted that 

the phenomena described above of women working fewer 

hours is part of a larger generational phenomenon, affecting not only physicians, but also other professionals as well 

(Bond et al 1998; Lang 2000; Gutner 2002). If the new 

generation of physicians prefers to work fewer professional 

hours, the FTE physician supply in the U.S. will be reduced.

By some indications, older physicians are reducing the 

hours they work (Cooper 2002b). For example, in New York, 

a recent survey finds that a significant proportion of physicians expect to reduce their hours worked in the year ahead 

(Salsberg et al forthcoming). If older physicians are also 

reducing their hours, it may lead to a decrease in total physician FTEs similar to that of the new generation of physicians.

To estimate how these lifestyle changes may affect 

the supply of physicians in the U.S. in the future, it was 

assumed that by 2020, physicians would work 10 percent fewer hours on average than presumed in the baseline model.5

 Table 4 presents the results of the scenario.

Under Alternative Scenario One, the supply of physicians is projected to grow by some 105,000 FTEs (13 percent) 

between 2000 and 2020 compared to the projected increase 

of 190,000 FTEs (24 percent) under the baseline projection. 

Thus, if lifestyle changes lead to a decrease in the hours 

worked by active physicians by 10 percent, the number of 

FTE physicians in 2020 would be 86,000 less than the baseline 

projections would suggest. The U.S. Census Bureau projects 

an 18 percent growth in the U.S. population, yielding a net 4 

percent drop in the FTE physician-to-population ratio. It is 

important to note that according to this model, the FTE physician-to-population ratio peaks in 2005 compared to a peak in 

2015 in the baseline model. Clearly, the lifestyle changes described above would limit the supply of physicians in the U.S.

Sensitivity Analysis: 

Alternative Scenario One

For a better understanding of the breadth of influence 

that lifestyle changes might have on the supply of physicians, 

a simple sensitivity analysis was performed by changing the 

assumption of how large the effect of lifestyle changes (i.e., 

the reduction in hours worked among physicians) would be 

by 2020. On the low-effect end, it was assumed that lifestyle changes would decrease hours worked by 5 percent by 

2020; whereas on the high-effect end, it was assumed that 

lifestyle changes would decrease hours worked by 20 percent by 2020. Table 5 presents the results of this analysis.

A decrease of 5 percent in the number of hours worked 

by physicians by 2020 is projected to result in an increase of 

about 145,000 physician FTEs during the time period and, in 

every practical sense, a stable FTE physician-to-population 

ratio. On the other hand, a decrease of 20 percent in the number of hours worked by physicians by 2020 seriously depletes 

the physician supply in absolute as well as relative terms. 

This is the first projection in which the absolute number 

5 Technically, to create this scenario, the FTE-to-physician ratio was assumed to decrease a total of 10 percent between 2000 and 2020 above and beyond the 

decrease already factored into the baseline model (2 percent), moving from 0.996 to 0.889. The figure of 10 percent was chosen as a result of research around 

the differences among male and female physicians’ work hours (Bobula 1980; Martin et al 1988; Schwartz et al 1988; Cooper 1994; AMWAC/AHIW 1996, 

1998; Sullivan and Buske 1998; Forte and Salsberg 1999), where much of the discussion around lifestyle changes among physicians originated.

TABLE 4

Supply of Physicians in the U.S., 2000-2020,

Alternative Scenario One Projections:

Physician Lifestyle Changes

Year

Baseline

FTE

Physicians

Lifestyle

Changes FTE

Physicians

U.S.

Population

(1,000s)

FTEs per

100k Pop.

2000 781,227 781,227 276,241 283

2005 844,464 824,004 288,286 286

2010 899,540 857,259 300,431 285

2015 942,145 877,625 313,116 280

2020 971,817 885,467 325,942 272

% Change 24% 13% 18% –4%
SIXTEENTH REPORT OF COGME 10 

of FTEs peaks before 2020. Clearly, the assumption about 

future lifestyle changes could have important implications 

for the projected supply of physicians in the U.S. in 2020.

Alternative Scenario Two:

Productivity Changes

Another important factor that can influence the available 

supply of physicians in the U.S. is physician productivity. 

Productivity, in this instance, is defined as output divided by 

time spent. Although the lifestyle changes above assumed 

a constant level of productivity and a decline in time spent 

practicing, here the focus is changes occurring in medical 

practice that allow physicians to practice more efficiently. 

New medical technologies, particularly in the area of information systems, could lead to an increase in physician 

productivity. For example, the electronic medical record 

could allow physicians to quickly, easily, and accurately access and assess all the necessary information on a patient’s 

history instead of having to order the file be sent to him, 

and then shuffling through the paper file. Estimates of the 

potential productivity gains through the use of new technologies or implementation of already existing technologies are 

widely variable (Blumenthal 2002; Masys 2002; Goldsmith 

et al 2003). A recent study suggests a potential gain of 20 

percent through the use of technology (Corrigan 2003).

.

TABLE 5

Supply of Physicians in the U.S., 2000-2020,

Alternative Scenario One Projections of

Physician Lifestyle Changes: Sensitivity Analysis

Year

Baseline

FTE

Physicians

5%

Lifestyle

Effect

FTE

Physicians

10%

Lifestyle

Effect

FTE

Physicians

20%

Lifestyle

Effect

FTE

Physicians

2000 781,227 781,227 781,227 781,227

2005 844,464 834,109 824,004 804,512

2010 899,540 877,981 857,259 818,775

2015 942,145 908,741 877,625 821,376

2020 971,817 926,635 885,467 813,210

% Change 24% 19% 13% 4%

To determine the effect of increased productivity on 

the supply of physicians, it was assumed that the physician workforce would be 20 percent more productive 

by 2020.6 Table 6 presents the results of the scenario.

Under Alternative Scenario Two, the supply of physicians is projected to grow by over 425,000 FTEs (55 

percent) between 2000 and 2020 compared to 190,000 (24 

percent) under the baseline projection. Thus, if physician 

productivity increases by 20 percent by 2020, the number 

of FTE physicians in 2020 would be 235,000 more than 

the baseline projections would suggest. The U.S. Census 

Bureau projects an 18 percent growth in the U.S. population between 2000 and 2020, yielding a net 31 percent 

increase in the FTE physician-to-population ratio. It is 

important to note that according to this model, the FTE 

physician-to-population ratio does not peak in the time period under investigation compared to a peak in 2015 in the 

baseline model. Clearly, productivity changes as described 

above could increase the supply of physicians in the U.S.

6 To estimate how changes in the level of productivity may affect the supply of physicians in the U.S. in the future, a measure of productivity change had 

to be determined. Because FTEs are the units of supply under consideration, it was possible, once again, to adjust the FTE-to-physician ratio to represent a 

change in productivity: as productivity increases, the FTE-to-physician ratio increases. When the assumption of a total productivity gain over the 20-year 

period (2000 through 2020) of 20 percent (which works out to be just slightly above 0.9 percent annually7) beyond the decrease (due to working fewer hours) 

already factored into the baseline model (2 percent) was used, the FTE-to-physician ratio moved from 0.996 in 2000 to 1.212 in 2020. This annual increase 

in productivity is well within reason. Overall productivity in the U.S. economy grew between 1.0 percent and 4.8 percent annually between 1993 and 2002 

(Bureau of Labor Statistics [BLS] 1993-2002). Quarterly increases since 2002 have generated larger annualized increases (BLS 2003).
SIXTEENTH REPORT OF COGME 11

TABLE 6

Supply of Physicians in the U.S., 2000-2020,

Alternative Scenario Two Projections:

Physician Productivity Increases

Year

Baseline

FTE

Physicians

Productivity

Increases 

FTE

Physicians

U.S.

Population

(1,000s)

Productivity

Increases

FTEs per

100k Pop.

2000 781,227 781,227 276,241 283

2005 844,464 888,592 288,286 308

2010 899,540 997,981 300,431 332

2015 942,145 1,104,550 313,116 353

2020 971,817 1,207,285 325,942 370

% Change 24% 55% 18% 31%

Sensitivity Analysis:

Alternative Scenario Two

On the low-effect end, it was assumed that physician productivity would increase by 10 percent; 

whereas on the high-effect end, it was assumed that 

physician productivity would increase by 30 percent. Table 7 presents the results of this analysis.

TABLE 7

Supply of Physicians in the U.S., 2000-2020,

Alternative Scenario Two Projections of

Physician Productivity Increases: 

Sensitivity Analysis

Year

Baseline

FTE

Physicians

10%

Productivity

Effect 

FTE

Physicians

20%

Productivity

Effect 

FTE

Physicians

30%

Productivity

Effect 

FTE

Physicians

2000 781,227 781,227 781,227 781,227

2005 844,464 865,967 888,592 912,432

2010 899,540 946,207 997,981 1,055,749

2015 942,145 1,016,904 1,104,550 1,208,729

2020 971,817 1,076,829 1,207,285 1,373,707

% Change 24% 38% 55% 76%

A physician productivity increase of 10 percent by 2020 

results in an increase of over 105,000 physician FTEs beyond the baseline projections of physicians. On the other 

hand, an increase of 30 percent in physician productivity 

leads to a substantially higher projected physician supply. 

It is difficult to believe that gains of this magnitude could 

be realized, which suggests that further study of the impact 

of physician productivity enhancements is in order. Nonetheless, it is clear that the particular assumptions about 

potential productivity gains have important implications 

for the projected supply of physicians in the U.S. in 2020.
SIXTEENTH REPORT OF COGME 12 

Alternative Scenario Three:

Hybrid Lifestyle/Productivity 

Changes

Combining the previous two alternative scenarios reveals 

a more complete picture. This scenario portrays an environment in which physicians are working more productively, 

but also are working fewer hours, having more time to spend 

on other pursuits, such as their families. Working from the 

previous scenarios, the relevant assumptions here include a 

reduction of 10 percent in hours worked, coupled with an increase in productivity of 20 percent between 2000 and 2020.7

Table 8 presents the projections derived from this scenario.

A consideration of the scenario with a similar change 

will project a growth in this scenario in which the supply of physicians will grow by almost 300,000 FTEs (38 

percent) between 2000 and 2020 compared to 190,000 

(24 percent) under the baseline projection. Thus, if both 

physician lifestyles change and productivity increases by 

2020, the number of FTE physicians in 2020 would be 

105,000 more than the baseline projections would suggest.

Sensitivity Analysis: Alternative 

Scenario Three

For a determination of the effects of a combination 

of alternative assumptions regarding lifestyle changes and 

productivity enhancements, a sensitivity analysis was developed. On the low-effect end, it was assumed lifestyle and 

7 In fact, because both scenarios are built around changing the FTE-to-physician ratio, the net effect modeled is equivalent to a 10 percent increase in the 

ratio, which is exactly the same as the low end of the sensitivity analysis for Alternative Scenario Two.

TABLE 8

Supply of Physicians in the U.S., 2000-2020,

Alternative Scenario Three Projections:

Hybrid Lifestyle/Productivity Changes 

Year

Baseline

FTE

Physicians

Lifestyle/

Productivity

Changes

FTE

Physicians

U.S.

Population

(1,000s)

Lifestyle/

Productivity

Changes

FTEs per

100k Pop.

2000 781,227 781,227 276,241 283

2005 844,464 865,967 288,286 300

2010 899,540 946,207 300,431 315

2015 942,145 1,016,904 313,116 325

2020 971,817 1,076,829 325,942 330

% Change 24% 38% 18% 17%

productivity changes would be small: a 5 percent lifestyle 

effect (fewer hours worked) and a 10 percent productivity increase. On the high-effect end, it was assumed that lifestyle 

and productivity changes would be great: a 20 percent lifestyle effect (fewer hours worked) and a 35 percent productivity increase. Table 9 presents the results of this analysis.

A physician productivity increase of 10 percent, coupled 

with a 5 percent reduction in hours worked because of 

lifestyle changes by 2020, results in an increase of about 

50,000 physician FTEs beyond the baseline projections of 

physicians. On the other hand, an increase of 35 percent 

in physician productivity, coupled with a 20 percent reduction in hours worked by 2020, leads to 166,000 more FTE 

physicians than those projected by the baseline model.

CONCLUSIONS: SUPPLY OF 

PHYSICIANS IN THE U.S., 2000-2020

Projections of the supply of physicians in the U.S. between 2000 and 2020 forecast that the supply of physicians 

will continue to grow in absolute terms throughout the period. Although the magnitude of the projected growth varies 

considerably, it is likely that the supply of physicians will 

grow between 100,000 and 300,000 FTE physicians during 

the time period, depending on the particular assumptions 

made about lifestyle changes and potential productivity gains 

in the future. The baseline physician supply projections suggest that by 2020 there will be 971,817 physicians practicing 

in the U.S. It is likely, however, that changes in physician 

lifestyle choices and in their level of productivity will have 
SIXTEENTH REPORT OF COGME 13

TABLE 9

Supply of Physicians in the U.S., 2000-2020,

Alternative Scenario Three Projections of

Hybrid Lifestyle/Productivity Changes: 

Sensitivity Analysis 

Year

Baseline

FTE

Physicians

5%

Lifestyle/

10%

Productivity

Changes

FTE

Physicians

10%

Lifestyle/

20%

Productivity

Changes

FTE

Physicians

20%

Lifestyle/

35%

Productivity

Changes

FTE

Physicians

2000 781,227 781,227 781,227 781,227

2005 844,464 855,080 865,967 877,134

2010 899,540 922,283 946,207 971,405

2015 942,145 978,098 1,016,904 1,058,917

2020 971,817 1,021,632 1,076,829 1,138,331

% Change 24% 31% 38% 46%

an effect on that growth. It is conceivable that these changes 

will have an overall effect of increasing the physician supply 

beyond the baseline projection level. The magnitude of that 

effect is unclear at this time, but it will probably be modest. 

Thus, it is also likely that the supply of physicians will fall 

somewhere in the range of 972,000 and 1,077,000 physicians.

Further, analysis of the model results and factors affecting the future supply of physicians suggest a number of 

areas of targeted research, including: the effectiveness of 

current efforts to increase the medical education capacity in 

the U.S.; changes in the rate of retirement among physicians 

and their ramifications; generational lifestyle changes and 

their potential effects on the physician workforce; changes 

in activity rates among physicians in terms of professional 

activities within and outside of medicine; productivity enhancements among the physician workforce; and issues 

related to the selection of specialties by young physicians 

and changes in historical specialty-specific rates of selection.
SIXTEENTH REPORT OF COGME 14 
SIXTEENTH REPORT OF COGME 15

Future Demand for Physicians, 2000-2020

OVERVIEW OF METHODOLOGY: 

BASELINE MODEL AND FACTORS 

AFFECTING FUTURE DEMAND

The baseline forecast of demand for physicians in 

the U.S. between 2000 and 2020 is based on the Federal 

Physician Demand Model (PDM). This model, developed 

and maintained by BHPr, HRSA, DHHS, produces projections of full-time physician equivalent demand by 

specialty for 1995 through 2020. For the purposes of this 

report, the years of interest are 2000 through 2020, and 

the specialty groups of interest are generalists and nongeneralists. This section presents forecasts of the total 

demand for physicians and factors affecting the overall 

demand for physicians in the U.S. Projections of demand 

for generalists and non-generalists appear in Section V.

The model’s approach is to assign populations to specific 

delivery settings and then to choose a staffing configuration 

for each setting. First, the model defines populations according to gender, age (groups include: 0-4, 5-17, 18-44, 45-64, 

8

 It should be noted that demand estimates for 2000 through 2002 are not based on the PDM results. Instead, demand for physicians in these years is assumed 

to be equal to the actual supply of physicians. There are several reasons for this assumption. First, since the conceptualization of demand in this report is 

the actual utilization of physicians, the actual numbers of FTE physicians is a more accurate representation of demand than anything that the model might 

generate. Second, the assumption of balance at the outset is appropriate and avoids making a statement about the current relationship between supply and 

demand that could distract from the goals of the report (to re-assess the relationship between supply and demand and supply and need going forward). 

Finally, since one cannot make recommendations that can produce more or fewer physicians in the past, it is a moot point about whether there was a surplus 

or shortage of physicians in 2000, 2001, or 2002. The challenge is to estimate the levels of supply, demand, and need and the potential gaps between them in 

the future.

9

 Although Figure 4 does not include complete age and gender details, these population characteristics are accounted for in the model. The purpose of 

Figure 4 is to show the variety of delivery settings and insurance statuses covered in the model.

65-74, 75-84, 85 and older), location (urban or rural), and 

insurance status. From these characteristics, a matrix of delivery settings is created. The model then distributes the U.S. 

population across these delivery settings. (Figure 4 shows a 

simplified matrix of these delivery settings.) Then, the model 

calculates the number of physicians necessary to meet the 

requirements of those populations based on how they are distributed across the delivery settings. These calculations are 

based on historical staffing patterns for the delivery settings. 

The data used to compile these historical trends are derived 

from the National Health Interview Survey (NHIS) and the 

National Ambulatory Medical Care Survey (NAMCS). The 

population projections used in the model are based on U.S. 

Census Bureau middle series estimates of population growth 

between 2000 and 2020 (Bannister et al 2001). The assumption most important to the accuracy of the model is that the 

utilization rates of the various populations included in the 

model and the staffing levels at the various delivery settings 

will remain at their historical levels (i.e., levels recorded during the early to mid-1990s) and constant over time through 

2020.8 A discussion of the effects of challenges to this assumption is included in the alternative scenarios section below.

FIGURE 49

PDM Population/Delivery Setting Matrix (Simplified)

Under 65

Rural Urban

Staff HMO* Staff HMO

IPA† HMO* IPA HMO

FFS‡ FFS

Medicaid Staff HMO Medicaid Staff HMO

Medicaid IPA HMO Medicaid IPA HMO

Medicaid FFS Medicaid FFS

No Insurance No Insurance

65 and Above

Medicare Staff HMO Medicare Staff HMO

Medicare IPA HMO Medicare IPA HMO

Medicare FFS Medicare FFS

*HMO = Health Maintenance Organization

 †IPA = Individual Practice Association

 ‡FFS = Fee for Service
SIXTEENTH REPORT OF COGME 16 

Conceptually, then, demand is being equated with use of 

physician services under a specific set of circumstances. Demand is not conceptualized in this model as what a population with certain characteristics might desire in terms of physicians, access to physicians, or physician services. In fact, 

in the absence of coercion, demand as defined in the model 

will consistently be lower than demand defined as population desire for services. This is an important conceptualization in terms of how to interpret the results of the forecasts 

presented below and in terms of how need is conceptualized 

in this report (for a discussion of need, see Section IV).

Table 10 presents the baseline model results.

The demand for physicians is projected to grow by almost 210,000 FTEs (26 percent) between 2000 and 2020. 

Over the same time period, the U.S. Census Bureau projects 

an 18 percent growth in the U.S. population, yielding a net 

7 percent growth in the demand for physicians as expressed 

in an FTE physician-to-population ratio. Unlike the supply 

of physicians, the demand for physicians is not projected to 

peak during the time period under investigation. Relative 

to the baseline supply projections, demand is projected to 

grow more quickly; thus, a shortage is projected. However, 

this is only one projection. What happens if other factors 

that affect demand for physicians are taken into account?

ALTERNATIVE DEMAND SCENARIOS 

AND ASSUMPTIONS

The first alternative scenario entails an accounting of the 

effect that economic growth has on demand for physicians. 

The second alternative scenario modifies the assumptions 

that the age-specific utilization rates are constant, suggesting that these rates are changing for all age groups, but most 

important for populations over 45 years of age. The final 

alternative comes out of the work begun by John Wennberg 

and colleagues (Wennberg and Cooper 1999) and most 

recently exemplified in Fisher et al’s (2003a, 2003b) just 

published multi-article research that suggests actual demand 

for services is much lower than current rates of utilization 

because of unnecessary service provision. The idea of unnecessary services is also related to work that suggests appropriate levels of demand for physician services are best 

exemplified in settings where earnest utilization review 

processes have been implemented. This line of reasoning 

is associated with Weiner’s (1994, 1995) work in the mid1990s examining HMO staffing levels and recent update 

examining large prepaid group practices (Weiner 2004).

For a more comprehensive assortment of physician 

demand projections, several scenarios are presented based 

on each perspective listed above. Each alternative scenario 

was built to represent the manipulation of one major factor affecting the future demand of physicians in the U.S., 

or two factors in the case of hybrid models. Below, the 

reasoning behind, and the results of, the projections generated are presented. For a better understanding of the 

ramifications of the assumptions accompanying each alternative scenario, sensitivity analyses were also performed.

Alternative Scenario One: 

Economic Factor

The first alternative scenario works from the perspective currently championed by Cooper et al (2002, 2003) 

(past proponents include Schwartz and colleagues in the 

late 1980s and early 1990s, and Roehrig and Eisenstein in 

1999). This perspective argues that four major factors drive 

demand for physician services: economic expansion, population growth, work effort of physicians, and services provided by other practitioners (i.e., non-physician clinicians). 

Cooper and colleagues suggest that the most important of 

the four factors affecting physician demand is economic 

expansion. They find a consistent correlation between the 

supply of physicians and economic growth. However, Cooper and colleagues suggest that the relationship is complex. 

Economic growth induces growth in demand for health services, causing a rise in health care spending. This growth in 

health care spending, in turn, leads to a growth in the health 

care workforce, of which physicians are an important part.

This perspective is certainly not without opponents 

(e.g., Grumbach 2002; Barer 2002; Weiner 2002). It is 

easy to believe that in an environment of increasing health 

care costs and declining budgets, resistance to this sort of 

perspective is going to arise. However, only one published 

research article has presented data that challenge Cooper 

and colleagues’ findings (Anderson et al 2003). As with 

any perspective, though, proponents have never claimed 

that the theory holds under all conditions and assumptions. 

TABLE 10

Demand for Physicians in the U.S., 

2000-2020:

Baseline Projections

Year

FTE

Physicians

U.S. 

Population

(1,000s)

FTEs per

100k Pop.

2000 781,227 276,241 283

2005 836,818 288,286 290

2010 883,245 300,431 294

2015 934,151 313,116 298

2020 987,937 325,942 303

% Change 26% 18% 7%
SIXTEENTH REPORT OF COGME 17

Nonetheless, the jury may still be out on this perspective, but the evidence supporting it is compelling enough 

to generate a scenario based on some of its principles.

The baseline model used in this report to predict future demand for services takes each of the factors identified by Cooper and colleagues into account except for a 

consideration of economic expansion. All data necessary 

to incorporate the suggested causal pathway between economic expansion and demand for physician services were 

unavailable to construct an alternative scenario. Thus, the 

causal process was greatly simplified and the findings of 

Cooper et al (2002) that the use of physician services increases approximately 0.75 percent for every 1.00 percent 

increase in a Nation’s gross domestic product (GDP) were 

employed. The scenario further assumed that GDP per 

capita will rise about 1.0 percent per year between 2000 

and 2020 (Heffler et al 2003). Figure 5 shows the historical 

relationship between the growth of GDP and the supply of 

physicians in the U.S. Table 11 presents the projections of 

physician demand after incorporation of the economic factor.

Under Alternative Scenario One, the demand for physicians is projected to grow by over 340,000 FTEs (44 percent) between 2000 and 2020. This scenario compares to 

a growth of 206,000 FTEs (26 percent) under the baseline 

demand scenario. Over the same time period, the U.S. 

Census Bureau projects an 18 percent growth in the U.S. 

population, yielding a net 22 percent growth in the demand 

FIGURE 5

Relationship Between Active Physician Supply and GDP, 1929-2000

1929

1970

1990

1945-60

2000

MD + DO

1980

300

250

200

150

100

$0 $10,000 $20,000 $30,000

GDP per Capita (1996 dollars)

Active Physicians per 100,000 of

Population

Insufficient supply

leading to

medical school

expansion

in the 1970s.

Sources:

CCMC

AMA

AOA

BHPr

Fein

Kletke

Stewart

BEA

Source: Cooper 2002a.

for physicians as expressed in an FTE physician-to-population ratio. The 22 percent increase in demand for physicians 

under this scenario far exceeds that (7 percent) predicted by 

the baseline model. It is interesting to note that the absolute 

growth in physician demand predicted under this scenario 

between 2000 and 2010 (19 percent) closely resembles that 

predicted by the BLS over the same time period (18 percent) and forecasts made by Cooper and colleagues (2002).

Sensitivity Analysis: 

Alternative Scenario One

Even though the predictions generated under the current alternative scenario are similar to other attempts to 

forecast physician demand in the future, it is important to 

understand how the results of the model might be different under an alternative set of assumptions about economic 

growth. Cooper et al (2002) point out that the assumption 

of the level of economic growth is a particularly important 

one for predictions incorporating this perspective. For a 

test of the effects of different assumptions about the rate 

of growth of the economy, a simple sensitivity analysis was 

performed. On the low-effect end, it was assumed that the 

U.S. economy would grow 0.5 percent annually between 

2000 and 2020; whereas on the high-effect end, it was 

assumed that the U.S. economy would grow 2.0 percent 

annually. Table 12 presents the results of this analysis.
SIXTEENTH REPORT OF COGME 18 

Although the levels of economic growth experienced in 

the late 1990s in the U.S. are unlikely to occur for any sustained length of time, it is just as unlikely that the economy 

would decline for any extended period of time. The levels 

of economic growth considered in these analyses appear 

quite reasonable. On the conservative side (a sustained 

slow-growing economy: 0.5 percent annual GDP growth), 

demand for physicians will increase by 270,000 physicians 

between 2000 and 2020 (35 percent). On the other hand, 

a sustained 2 percent annual growth in the economy (a rate 

much closer to that in the early 1990s and to what has been 

projected over the next decade [Heffler et al 2003]) translates 

into a much more substantial growth of close to 400,000 FTE 

physicians between 2000 and 2020 (64 percent). The effect 

of economic growth is substantial, regardless of the level of 

TABLE 11

Demand for Physicians in the U.S., 2000-2020,

Alternative Scenario One Projections:

Economic Factor 

Year

Baseline

FTE

Physicians

Economic

Factor

FTE

Physicians

U.S.

Population

(1,000s)

Economic

Factor

FTEs per

100k Pop.

2000 781,227 781,227 276,241 283

2005 836,818 849,494 288,286 295

2010 883,245 931,050 300,431 310

2015 934,151 1,022,643 313,116 327

2020 987,937 1,123,243 325,942 345

% Change 26% 44% 18% 22%

economic growth assumed. Whether economic growth is the 

cause of physician demand growth is impossible to determine 

within the scope of this report. But even if they are only correlated, the end result will be the same: economic growth 

seems to coincide with growth in the demand for physicians.

Alternative Scenario Two: Changes 

in Age-Specific Utilization Rates

One assumption of the baseline model is that historical 

utilization rates will remain constant over time. With respect 

to age, independent investigation shows that utilization 

rates are changing. Most observers are familiar with findings suggesting that as the population grows older, overall 

utilization will increase because utilization rates increase 

TABLE 12

Demand for Physicians in the U.S., 2000-2020,

Alternative Scenario One Projections of

Economic Factor: Sensitivity Analysis 

Year

Baseline

FTE

Physicians

0.5% Annual

GDP Growth

FTE

Physicians

1.0% Annual

GDP Growth

FTE

Physicians

2.0% Annual

GDP Growth

FTE

Physicians

2000 781,227 781,227 781,227 781,227

2005 836,818 843,130 849,494 862,380

2010 883,245 906,806 931,050 981,678

2015 934,151 977,310 1,022,643 1,120,300

2020 987,937 1,053,234 1,123,243 1,278,864

% Change 26% 35% 44% 64%
SIXTEENTH REPORT OF COGME 19

with age. As indicated in Figure 6, the number of Americans over 65 years of age is increasing and will increase 

significantly in the coming years. Figure 7 documents the 

increased use of inpatient services by age. Clearly, the aging of the population is leading to an increase in demand for 

services in America. However, if one examines utilization 

rates over time, especially physician office visits, it becomes 

evident that utilization rates by age group are changing.

Analysis of the National Ambulatory Medical Care 

Survey (NAMCS) data from 1980, 1990, and 2000 on 

visits to physician offices by age group (Figure 8) indicates that the number of physician visits per capita for age 

groups over 45 years of age have been increasing over 

the past few decades. There is reason to believe that this 

trend will continue and may even accelerate as the babyboom generation ages. The baby-boom generation has 

grown up with high expectations for health care and has 

experienced higher utilization rates than those of previous 

generations. In addition, as the baby-boomers age, many, 

but certainly not all, will have disposable income that they 

may choose to spend on health care (Knickman et al 2003).

Between 1980 and 2000, crude per capita visits to 

physician offices increased from 2.4 to 2.9. However, this 

increase was not evenly distributed across age groups. The 

FIGURE 6

Number of Americans 65 and Over and 85 and Over, 2000-2030

Source: U.S. Census Bureau Population Projections.

65+: 104% Increase from 2000-2030

85+: 120% Increase from 2000-2030

65+ 85+

largest gain was experienced among persons 75 to 84 years 

of age, increasing from 3.5 visits to 6.3 visits annually. All 

other groups above age 45 experienced gains as well, except 

the 85 years of age and above group. It turns out, however, 

that even though there was a global increase in utilization, 

for persons in the 15- to 24-year-old and the 25- to 34-yearold age groups, utilization rates declined between 1980 and 

2000. Further, the more recent changes in utilization (i.e., 

1990 compared to 2000) demonstrated a uniform set of increases and declines, with all groups below age 45 having 

experienced declines in annual per capita visits to physician offices and those age 45 and above having experienced 

increases in annual per capita physician office visit rates.

One explanation for the rise in use among those over 45 

years of age is that it reflects the investment of many billions of 

dollars in medical research interventions. These interventions 

may well be leading to increased demand for medical services.

For the observed changes in age-specific utilization 

rates to be taken into account, a scenario was constructed 

that represented a continuation of the observed 1990 

through 2000 trends between 2000 and 2010 and between 

2010 and 2020.10 Under this scenario, not only is the effect of the aging of the population considered, but also the 

trends in age-specific utilization rates (declining among 

10 For this scenario, the 10-year relative increases or declines in visits for each age group were calculated, using 2000 as the base year. These relative 

increases or declines were then applied to the baseline projections of FTE physician demand to generate the alternative FTE physician demand projections. 

The process was then repeated for 2020 using the 2010 projections as the base year. Projections for the intervening years of 2005 and 2015 were calculated 

by halving the adjustments made to the 2010 and 2020 baseline projects and by applying them to the 2005 and 2015 baseline projections, respectively.
SIXTEENTH REPORT OF COGME 20 

FIGURE 7

Days of Care in Short-Stay Hospitals, 1999

Number of adult and pediatric days excluding care for newborns

1,908

1,386

776

474

353 303

75 Plus

0

500

1,000

1,500

2,000

2,500

Under 18 18-44 45-54 55-64 65-74

Age

Days of Care per 1,000 Population

Source: Centers for Disease Control and Prevention (CDC), National Health Interview Survey, as reported in

National Center for Health Statistics. Health, United States, 2001.

FIGURE 8

Estimates of Ambulatory Care Visits to Physician Offices and Clinics, 

1980, 1990, and 2000

Source: CDC National Center for Health Statistics. National Ambulatory Medical Care Surveys 1980, 1990, 2000. 

Web site: www.cdc.gov/nchs/

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Under 5 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85 and

over Age

1980 1990 2000

Average Number of

Visits per User
SIXTEENTH REPORT OF COGME 21

the younger population and increasing among the older 

population) are also taken into account. Table 13 presents 

the projections made based on this alternative scenario.

Under Alternative Scenario Two, the demand for physicians is projected to grow by close to 330,000 FTEs (42 

percent) between 2000 and 2020 in comparison with the 

206,000 FTE growth (26 percent) predicted by the baseline 

model. Over the same time period, the U.S. Census Bureau 

projects an 18 percent growth in the U.S. population, yielding a net 20 percent growth in the demand for physicians 

as expressed in an FTE physician-to-population ratio. It 

is important to observe the explosion of demand for physicians in the years after 2010, when the combined effect of 

an aging population and the increased utilization rates of the 

above age 45 group are evident. The 20 percent increase in 

demand for physicians under this scenario far exceeds that 

(7 percent) predicted by the baseline model. It is interesting to note that the absolute growth in physician demand 

predicted under this scenario between 2000 and 2010 (17 

percent) closely resembles the results of the previous alternative scenario that represented an attempt to account for 

the effect of economic expansion on physician demand (19 

percent). Further, as mentioned above, other predictions of 

physician demand unrelated to the current project are also 

consistent with the predictions of this alternative scenario.

Sensitivity Analysis:

Alternative Scenario Two

The predictions generated under the current alternative 

scenario are similar to other attempts to forecast physician 

TABLE 13

Demand for Physicians in the U.S., 2000-2020,

Alternative Scenario Two Projections:

Changes in Utilization Rates 

Year

Baseline

FTE

Physicians

Changing

Utilization

Rates

FTE

Physicians

U.S.

Population

(1,000s)

Changing

Utilization

Rates

FTEs per

100k Pop.

2000 781,227 781,227 276,241 283

2005 836,818 841,384 288,286 292

2010 883,245 917,075 300,431 305

2015 934,151 1,008,022 313,116 322

2020 987,937 1,108,916 325,942 340

% Change 26% 42% 18% 20%

demand in the future. Despite this fact, it is important to understand how the results of the model might be different under an alternative set of assumptions about the change in agespecific utilization rates, especially in light of the explosive 

nature of the combined effects of an aging population and increased utilization among the older population. For a test of 

the effects of different magnitudes of change in age-specific 

physician utilization rates, a simple sensitivity analysis was 

performed. On the one hand, it was assumed that the agespecific utilization rates would change at half the rate they 

changed between 1990 and 2000. On the other hand, it was 

assumed that the age-specific utilization rates would change 

at one and a half times the rate they changed between 1990 

and 2000.11 Table 14 presents the results of this analysis.

The levels at which age-specific rates of utilization 

will grow in the future will have serious implications for 

the demand for physicians in the U.S. As is evident from 

the alternative projections of the high and low scenarios of 

utilization rate growth, the range of the effect is approximately 220,000 FTE physicians. In the low-growth scenario, 

demand for physicians grows to just over 1 million FTEs in 

2020 (31 percent), a figure significantly lower than predicted 

in the initial projections taking into account age-specific 

utilization rate changes. Again, it is important to observe 

that almost 75 percent of the increase occurs between 2010 

and 2020, testament to the combined effect mentioned 

above. On the other hand, if the changes in the utilization 

rates accelerate as is the case in the high-growth scenario, 

the demand for physicians may increase to almost 1.25 million FTE physicians, or 381 FTE physicians per 100,000 

population. Since the aging of the U.S. population cannot 

11 To be more specific, on the low end, it was assumed that age-specific utilization rates would change between 2000 and 2010, and between 2010 and 2020, 

at half the magnitude observed between 1990 and 2000; whereas on the high end, it was assumed that age-specific utilization rates would change between 

2000 and 2010, and between 2010 and 2020, at one-and-a-half times the magnitude observed between 1990 and 2000.
SIXTEENTH REPORT OF COGME 22 

be reversed at this point, the effects of changes to the agespecific physician utilization rates are extremely important. 

Although this alternative scenario projects a wide range of 

potential effects associated with these changes, it is clear that 

closer examination and future research should be targeted at 

understanding the dynamics and trajectories of these rates.

Alternative Scenario Three: 

Elimination of Unnecessary 

Services/Increased Utilization 

Review

The first two alternative scenarios examined factors 

that were either inadequately taken into account or ignored 

completely in the baseline projections. However, the issue in the third alternative scenario deals with a different 

kind of problem in the baseline projections. This imperfection is that of the model, which too closely resembles 

reality, including not only the beneficial qualities of the 

current health care delivery system, but also its faults. In 

particular, unnecessary services, according to some, 

are common in the current health care delivery system.

There are a number of reasons to believe some current use 

is unnecessary or only marginally beneficial. Possible causes 

include: poor physician performance due to an oversupply of 

physicians in a geographical area; the complexities of current 

treatment modalities and the inability of individual physicians to sort through them competently enough to understand 

which test or treatment is appropriate; advertisements targeted toward the public that in turn induce patients to demand 

services from their physicians; the financial pressure on facilities; outright greed of a small minority in the medical proTABLE 14

Demand for Physicians in the U.S., 2000-2020,

Alternative Scenario Two Projections of

Changes in Utilization Rates: Sensitivity Analysis

Year

Baseline

FTE

Physicians

1/2

Historical

Rate of

Change

FTE

Physicians

Historical

Rate of

Change

FTE

Physicians

1-1/2

Historical

Rate of

Change

FTE

Physicians

2000 781,227 781,227 781,227 781,227

2005 836,818 835,193 841,384 853,556

2010 883,245 847,615 917,075 938,297

2015 934,151 959,585 1,008,022 1,078,499

2020 987,937 1,026,854 1,108,916 1,240,453

% Change 26% 31% 42% 59%

fession; the ongoing medical liability crisis and the resultant 

practice of “defensive medicine”; a financing/reimbursement 

system that gives incentives to provide services without regard to outcomes. Regardless of the causes of the unnecessary provision, a long-standing, compelling argument exists 

that a substantial number of services provided by physicians 

and other practitioners in the health care delivery system are 

simply unnecessary or only marginally beneficial. Further, 

it is argued that it is these unnecessary services that are driving up health care costs and spending in the aggregate. And 

thus, proponents of this perspective argue that eliminating 

these unnecessary and marginal services provides two essential goods: efficiency and cost savings (Fisher et al 2003).

The work of Wennberg and colleagues showing the 

diminishing rates of benefit to the community of additional 

physicians can certainly be thought of as supporting this perspective. Recently, the work of Fisher et al (2003a, 2003b) 

showing the lack of relationship (and sometimes negative 

relationship) between the provision of services, level of 

spending on services, health care outcomes, and patient satisfaction provided another analysis supporting the perspective.

Coming from a slightly different perspective, Weiner 

(1994, 1995, 2004) and others (Hart et al 1997; Goodman 

et al 1996) have attempted to estimate demand for physician 

services in a way that bypasses these unnecessary services by 

examining closed, organized systems of health care delivery 

that employ more or less rigorous utilization review. In the 

early and mid-1990s, these examinations revolved around 

staff-model HMOs. This work has most recently evolved to 

examine large prepaid group practices having contracts with 

managed care plans (Weiner 2004). The earlier work found 
SIXTEENTH REPORT OF COGME 23

that staff-model HMOs were able to provide equivalent quality of care with drastically smaller physician staffing levels. 

Those who looked more closely at these organizations found 

that patients were actually using many out-of-network services and challenged this early work (Hart et al 1997). This 

work continues, however, and the most recent updates show 

that although in the past these delivery systems may have 

required lower staffing levels, over time they have expanded. 

However, the expansion has not quite reached the levels 

observed outside of these delivery systems (Weiner 2004).

For this alternative scenario, the most important issue 

is estimating a level of unnecessary services (or thought 

of differently, a percentage of services that would not pass 

rigorous utilization review). The most recent work (Fisher 

et al 2003b; Weiner 2004), suggests that approximately 

26.5 percent of the services are unnecessary or would not 

occur under a more rigorous system of utilization review. With that assumption made, Table 15 presents the 

resultant projections of physician demand through 2020.12

Under this alternative scenario, the growth in physician 

demand is approximately 150,000 FTE physicians (26 percent) between 2000 and 2020, in relative terms equivalent 

to the baseline model. The results are the same for demand 

expressed as a ratio of FTE physicians to 100,000 population. 

However, in absolute terms, the results of this scenario are remarkable. Whereas the baseline model predicts demand close 

to 1 million FTE physicians in 2020, this alternative forecasts 

less than a 750,000 FTE demand for physicians. This alternative scenario suggests that demand for physicians in 2020 

will be smaller than the baseline model predicts for 2000.

Sensitivity Analysis:

Alternative Scenario Three

One estimate of the effect of eliminating unnecessary 

services is presented above. Below, a range is constructed 

around this estimate, and its implications for physician 

demand are presented. In the low-effect scenario, only 20 

percent could be identified and eliminated as unnecessary 

services; whereas in the high-effect scenario, a full third of 

services could be identified and eliminated as unnecessary. 

Table 16 presents the results. Clearly, the relative change 

in demand for physicians is unaffected by the assumption of 

the level of unnecessary services that could be identified and 

eliminated. Rather, the absolute level of demand is affected.

12 Unlike all the other scenarios presented above, in this scenario and in all hybrid scenarios that include an assumption about unnecessary services, the 

effect is applied to the year 2000 demand estimates. This application is meant to represent the position that current levels of utilization suffer from the same 

problem of unnecessary services as future years will.

TABLE 15

Demand for Physicians in the U.S., 2000-2020,

Alternative Scenario Three Projections:

Reduction of Unnecessary Services

Year

Baseline

FTE

Physicians

26.5%

Reduction in

Services

FTE

Physicians

U.S.

Population

(1,000s)

26.5%

Reduction in

Services

FTEs per

100k Pop.

2000 781,227 574,202 276,241 208

2005 836,818 615,061 288,286 213

2010 883,245 649,185 300,431 216

2015 934,151 686,601 313,116 219

2020 987,937 726,133 325,942 223

% Change 26% 26% 18% 7%
SIXTEENTH REPORT OF COGME 24 

Alternative Scenarios Four and Five: 

Hybrid Models—Economic Expansion 

and Unnecessary Services/ 

Increased Utilization Review; 

Changes in Age-Specific Utilization 

Rates and Unnecessary Services/

Increased Utilization Review

The next two alternative scenarios involve an attempt 

to bring together the alternative demand scenarios presented 

previously. In both Alternative Scenarios Four and Five, the 

TABLE 16

Demand for Physicians in the U.S., 2000-2020,

Alternative Scenario Three Projections of

Reduction of Unnecessary Services: Sensitivity Analysis

Year

Baseline

FTE

Physicians

20.0%

Reduction in

Services

FTE

Physicians

26.5%

Reduction in

Services

FTE

Physicians

33.3%

Reduction in

Services

FTE

Physicians

2000 781,227 624,982 574,202 521,078

2005 836,818 669,454 615,061 558,158

2010 883,245 706,596 649,185 589,125

2015 934,151 747,321 686,601 623,079

2020 987,937 790,349 726,133 658,954

% Change 26% 26% 26% 26%

predicted expansion in demand due to either continued economic expansion or increasing rates of utilization by the portion of the population that is growing the fastest is coupled 

with efforts to identify and eliminate unnecessary service 

provision. Alternative Scenario Four couples economic expansion with utilization review, whereas Alternative Scenario 

Five couples increasing utilization predictions with utilization 

review. Tables 17 and 18, respectively, present the results.

Applying the assumptions of eliminating unnecessary 

services certainly appears to control the great increases 

in demand for physicians predicted by either economic 

TABLE 17

Demand for Physicians in the U.S., 2000-2020,

Alternative Scenario Four Projections:

Economic Factor/Increased Utilization Review 

Year

Baseline

FTE

Physicians

Economic

Factor/

Increased UR*

FTE

Physicians

U.S.

Population

(1,000s)

Economic

Factor/

Increased UR*

FTEs per

100k Pop.

2000 781,227 574,202 276,241 208

2005 836,818 624,378 288,286 217

2010 883,245 684,322 300,431 228

2015 934,151 751,642 313,116 240

2020 987,937 825,583 325,942 253

% Change 26% 44% 18% 22%

*UR = Utilization Review
SIXTEENTH REPORT OF COGME 25

13 Because the relative change in demand does not change at different levels of unnecessary services, sensitivity analyses are not presented here. However, 

such analyses are available upon request from the authors.

14 That is, utilization of services is related to whether services are necessary, but the desire for services has nothing whatsoever to do with whether they are 

necessary.

expansion or the increasing rates of utilization of services among specific groups within the population. The 

demand for close to 300,000 FTE physicians is eliminated under both of these alternative hybrid scenarios.13

CONCLUSIONS: DEMAND FOR 

PHYSICIANS IN THE U.S., 2000-2020

The baseline predictions of growth in the demand for physicians suggest that demand will increase by almost 210,000 

FTE physicians by 2020, totaling over 987,000 physician 

FTEs. When other factors are taken into consideration, such 

as economic expansion and the observed increasing rates of 

utilization among those age 45 and above, growth in demand, 

in fact, may increase an additional 300,000 FTE physicians 

during that same time period. Yet, this growth is logical given 

the aging of the population; the Nation’s investments in new 

and improved health and medical care services and procedures; and the Nation’s continued increase in wealth. Given 

the findings presented above, it is likely that the Nation will 

demand between 1,025,000 and 1,240,000 physicians in 2020.

Further, although the Bureau of Labor Statistics 

(BLS) uses a different forecasting methodology, it is 

worth noting that the BLS forecast for physician job 

growth between 2000 and 2010 is 18 percent (Hecker 

2001). In this report, the estimate of growth in demand 

for physicians between 2000 and 2010 is between 17 

percent and 19 percent. The similarities in estimated demand provide some comfort with the current forecasts.

TABLE 18

Demand for Physicians in the U.S., 2000-2020,

Alternative Scenario Five Projections:

Changes in Utilization Rates/Increased Utilization Review

Year

Baseline

FTE

Physicians

Changing

Utilization/

Increased UR

FTE

Physicians

U.S.

Population

(1,000s)

Changing

Utilization/

Increased UR

FTEs per

100k Pop.

2000 781,227 574,202 276,241 208

2005 836,818 618,417 288,286 215

2010 883,245 674,050 300,431 224

2015 934,151 740,896 313,116 237

2020 987,937 815,053 325,942 250

% Change 26% 42% 18% 20%

On the other hand, an important factor that is seldom 

taken into account in predictions of demand for physician 

services is the level of unnecessary services. Because demand is conceptualized as utilization of services (rather 

than the desire for services), consideration of unnecessary 

services is appropriate.14 The alternative scenarios presented previously with regard to unnecessary services 

certainly imply that it is an important factor in physician 

workforce planning. However, the most difficult challenge to this perspective is developing solutions that can 

effectively identify and eliminate the unnecessary services. 

In the words of one major proponent of this perspective:

Previous research has shown that vulnerable 

populations may be harmed by reduced access 

to care or as a consequence of public hospital 

closures. It is not always clear, for example, 

whether services such as specialist consultations are wasteful or beneficial. The potential 

adverse impact of reductions in the use of beneficial services and disruptions in current practice 

patterns underscores the importance of further 

research on these issues and of the implementation and evaluation of demonstration projects 

intended to improve quality of care and promote 

conservative approaches to managing patients 

with chronic disease (Fisher et al 2003, p. 297).

The implication of this position is to base policy decisions not on these initial exploratory analyses of utilization 

and outcomes, but rather on more targeted research results.
SIXTEENTH REPORT OF COGME 26 
SIXTEENTH REPORT OF COGME 27

Future Need for Physicians, 2000-2020

OVERVIEW OF METHODOLOGY: 

BASELINE MODEL AND FACTORS 

AFFECTING FUTURE NEED

The need for physicians, like demand, is defined with 

respect to current patterns of use of physician services. However, the calculation of need also includes the estimated levels 

of use of those who are currently uninsured if they were to be 

insured. Thus, the need for physicians is defined as the sum 

of current use plus anticipated use of the currently uninsured.

This conceptualization of need assumes that on average 

persons with ready access to health services will seek services commensurate with their need for those services. It also 

assumes that persons currently uninsured would use services 

at levels equal to those who are insured. In addition, based on 

previous research on the non-financial barriers to health care 

(e.g., racial disparities), it is assumed that the removal of such 

access barriers will also lead to a modest increase in use for 

all populations by 2.0 percent (Vector Research, Inc. 1995).

The baseline forecast of need for physicians in the 

U.S. between 2000 and 2020, again, is based on the Physician Demand Model (PDM). This model, developed and 

maintained by the BHPr, HRSA, DHHS, produces projections of full-time physician equivalents by specialty for 

1995 through 2020. For the purposes of this report, the 

years of interest are 2000 through 2020, and the specialty 

groups of interest are generalists and non-generalists. Es15 The organization used in the supply and demand sections of this report is not used in this section because the baseline PDM does not provide estimates 

of need for physicians as conceptualized here. In the previous sections, to differentiate baseline model projections clearly from the alternative scenarios, the 

baseline estimates were reported separately. In the case of need, by definition, the baseline PDM projections did not represent need as conceptualized in this 

report.

timates of need are generated by relaxing the assumption of 

historical insurance rates and assuming that all uninsured 

in the Nation would have (or would be provided) insurance. These assumptions are the basis for the first baseline 

projections.15 Table 19 presents baseline predictions of the 

need for physicians in the U.S. between 2000 and 2020.

It is important to note that this conceptualization of need 

is unconventional. Typically, need is defined according to 

either an ideal standard of health care or staffing found existing in a limited population, geographic area, or health care 

delivery system. In the final analysis, however, these types of 

conceptualizations are subjective and open to unknown (and 

sometimes unknowable) biases on any number of counts. 

The potential biases and their direction can begin to be listed 

by using an empirical conceptualization of need. First, the 

estimates of need based on this conceptualization, in most 

cases, will be higher than the estimates of demand (i.e., use). 

One possible scenario that would lead to higher demand than 

need would be one in which the uninsured population actually had higher rates of use as uninsured than they would with 

insurance. Second, the estimates of need are likely to underestimate the actual physician needs of the population. That 

is, there are other barriers to use beyond insurance and the 

non-financial barriers for which the baseline model cannot 

account. On the other hand, some would suggest that an estimate of physician need should exclude unnecessary services. 

Several alternative scenarios below present this perspective.

As described above, in the baseline projections, the 

approximately 41 million persons (Garrett, Nichols, and 

Greenman 2001) in the U.S. population who are currently 

uninsured are assumed to have insurance and to use services 

at the same rate as those who have historically had insurance. 

In the baseline model, the need for physicians is projected to 

grow by almost 300,000 FTEs (37 percent) between 2000 and 

2020. Over the same time period, the U.S. Census Bureau 

projects an 18 percent growth in the U.S. population, yielding a net 16 percent growth in the per capita need for physicians as expressed in an FTE physician-to-population ratio. 

Unlike the supply of physicians, the need for physicians is 

not projected to peak during the time period under investigation. Moreover, relative to the baseline supply projections, 

the need for physicians is projected to grow more quickly; 

thus, a shortage of physicians is implied. The next section 

presents alternative forecasts of the need for physicians and 

factors affecting the overall need for physicians in the U.S.

TABLE 19

Need for Physicians in the U.S., 

2000-2020:

Baseline Projections

Year

FTE

Physicians

U.S. 

Population

(1,000s)

FTEs per

100k Pop.

2000 781,227 276,241 283

2005 907,758 288,286 315

2010 959,036 300,431 319

2015 1,014,992 313,116 324

2020 1,073,641 325,942 329

% Change 37% 18% 16%
SIXTEENTH REPORT OF COGME 28 

ALTERNATIVE NEED SCENARIOS 

AND ASSUMPTIONS

The first and second alternative scenarios presented 

below combine the baseline projections (full insurance 

assumptions) with scenarios identified in the demand section of this report (specifically, the effect of changing 

age-specific physician utilization rates and the effect of the 

identification and elimination of unnecessary services, respectively). A final scenario that combines the assumptions 

of a fully insured population, the changes in age-specific 

utilization rates, and the identification and elimination of 

unnecessary services is presented and discussed. For each 

alternative scenario, a sensitivity analysis is presented.

Alternative Scenario One: 

Changes in Age-Specific Utilization 

Rates

In the first alternative scenario predicting need for 

physicians in the U.S. between 2000 and 2020, the effects 

of continued changes in the age-specific physician utilization rates discussed in the previous section on demand are 

coupled with the effects of fully insuring the population of 

the U.S.16 It is noteworthy that the assumptions with respect 

to the changes in utilization rates are the same as those assumptions for Alternative Scenario Two in the demand 

section (i.e., the changes in age-specific physician utilization rates observed between 1990 and 2000 would continue 

between 2000 and 2010 and between 2010 and 2020). 

Table 20 presents the ramifications of making these assumptions on the need for physicians between 2000 and 2020.

16 This admixture of need and demand is made possible by having defined both in terms of utilization.

Under Alternative Scenario One, the need for physicians is projected to almost double to over 1,500,000 FTEs 

between 2000 and 2020. Over the same time period, the 

U.S. Census Bureau projects an 18 percent growth in the 

U.S. population, yielding a net 65 percent growth in the 

per capita need for physicians as expressed in an FTE 

physician-to-population ratio, moving from 283 physicians 

per 100,000 population to a staggering 468. The tremendous growth in the need for physicians in this scenario is 

testament to the gravity of changing rates of utilization.

Sensitivity Analysis: 

Alternative Scenario One

One major assumption of the need projections is that 

once insured, the historically uninsured will use physician 

services at the same rate as the historically insured. For 

each alternative scenario presented in the need section, the 

sensitivity analysis will relax that assumption by examining two levels of utilization of services by the uninsured. 

On the low-use end, it is assumed that once insured, the 

historically uninsured will use services at half the rate of 

the historically insured. On the high-use end, it is assumed 

that once insured, the historically uninsured will use services 

at twice the rate of the insured. Both assumptions are legitimate, because some have argued that the uninsured are 

likely to be younger and healthier than the insured (which 

includes the older population on Medicare). Thus, the 

uninsured are in less need of services than the historically 

insured. At the same time, others have argued that the uninsured are likely to be poor, un- or underemployed, and 

thus in need of greater services than the historically insured. 

Table 21 presents the results of this sensitivity analysis.

TABLE 20

Need for Physicians in the U.S., 2000-2020,

Alternative Scenario One Projections:

Changes in Utilization Rates

Year

Baseline

FTE

Physicians

Changing

Utilization

Rates

FTE

Physicians

U.S.

Population

(1,000s)

Changing

Utilization

Rates

FTEs per

100k Pop.

2000 781,227 781,227 276,241 283

2005 907,758 977,658 288,286 339

2010 959,036 1,125,803 300,431 375

2015 1,014,992 1,309,650 313,116 418

2020 1,073,641 1,523,984 325,942 468

% Change 37% 95% 18% 65%
SIXTEENTH REPORT OF COGME 29

If the historically uninsured use physician services 

at half the rate of the historically insured population, between 2000 and 2020 there will be an increase of close to 

700,000 (89 percent) physician FTEs. On the other hand, 

if the historically uninsured are on average more inclined 

to use physician services, the model projects an increase 

in need of over 800,000 (104 percent) FTE physicians by 

2020. This analysis demonstrates that further research is 

needed to determine the exact effect of providing insurance to the historically uninsured population in the U.S. 

Whether the historical levels of utilization continue to hold 

in the future will have, as shown above, an effect on the 

number of physicians needed to adequately serve the population. Moreover, the analysis makes explicit the fact that 

assumptions about potential future changes in age-specific 

utilization rates have a much larger effect than assumptions 

about the physician utilization of the historically uninsured.

Alternative Scenario Two: 

Elimination of Unnecessary 

Services/Increased Utilization 

Review

As mentioned previously, in this second alternative 

scenario predicting need for physicians in the U.S. between 

2000 and 2020, the effects of being able to ferret out unnecessary services through a rigorous utilization review 

process identified in the previous section on demand are 

coupled with the effects of fully insuring the population of 

the U.S. It is noteworthy that the assumptions with respect 

to unnecessary services are the same as those for Alternative 

Scenario Three in the demand section (i.e., approximately 

26.5 percent of the services provided currently are unnecesTABLE 21

Need for Physicians in the U.S., 2000-2020,

Alternative Scenario One Projections of

Changes in Utilization Rates: Sensitivity Analysis

Year

Baseline

FTE

Physicians

Low

Utilization

Rates

FTE

Physicians

Equivalent

Utilization

Rates

FTE

Physicians

High

Utilization

Rates

FTE

Physicians

2000 781,227 781,227 781,227 781,227

2005 907,758 939,416 977,658 1,037,510

2010 959,036 1,084,913 1,125,803 1,189,614

2015 1,014,992 1,266,010 1,309,650 1,377,614

2020 1,073,641 1,477,711 1,523,984 1,596,006

% Change 37% 89% 95% 104%

sary and these services could be identified and prevented). 

Table 22 presents the results associated with this scenario.

Under this alternative scenario, the percentage growth 

(37 percent) in need for physicians is exactly the same as the 

baseline need projections, as was the case in the hybrid alternative models in the demand section. Again, it is interesting 

to note that although the relative change in need for physicians 

is the same, the level of service use is significantly lower.

Sensitivity Analysis: 

Alternative Scenario Two

The sensitivity analysis presented below, in Table 23, 

shows the effect of altering the assumption of use among 

the historically uninsured once they become insured.

Alternative Scenario Three: 

Changes in Age-Specific Utilization 

Rates; Unnecessary Services/

Increased Utilization Review Hybrid

In the final scenario, assumptions are made beyond the 

baseline need model that incorporate both changes in agespecific utilization rates and the identification and elimination of unnecessary physician services through 2020. Combining all factors is an attempt to predict the future need for 

physicians in the U.S. the most accurately. The assumptions 

in this scenario are exactly the same as the main assumptions 

on physician need in Alternative Scenarios One and Two. 

Table 24 presents the results associated with this scenario.
SIXTEENTH REPORT OF COGME 30 

Under the final alternative scenario, the need for physicians is projected to increase substantially to more than 

1,120,000 FTEs (95 percent) between 2000 and 2020. 

This scenario is slightly less than 50,000 FTE physicians 

higher than the baseline need prediction. Over the same 

time period, the U.S. Census Bureau projects an 18 percent 

growth in the U.S. population, yielding a net 65 percent 

growth in the per capita need for physicians as expressed 

in an FTE physician-to-population ratio, moving from 

208 physicians per 100,000 population to 344. Although 

the need for physicians does grow dramatically, efforts to 

identify and eliminate unnecessary services assert control 

over the growth, limiting the effects of changing patterns 

of physician utilization among a fully insured population.

TABLE 22

Need for Physicians in the U.S., 2000-2020,

Alternative Scenario Two Projections:

Reduction of Unnecessary Services

Year

Baseline

FTE

Physicians

26.5%

Reduction in

Services

FTE

Physicians

U.S.

Population

(1,000s)

26.5%

Reduction in

Services

FTEs per

100k Pop.

2000 781,227 574,202 276,241 208

2005 907,758 667,202 288,286 231

2010 959,036 704,891 300,431 235

2015 1,014,992 746,019 313,116 238

2020 1,073,641 789,126 325,942 242

% Change 37% 37% 18% 16%

Sensitivity Analysis: 

Alternative Scenario Three

Table 25 presents the results of lower and higher 

rates of utilization among the historically uninsured on 

the projections of the need for physicians between 2000 

and 2020 for Alternative Scenario Three. As suspected, 

the increases in physician need predicted by the model are 

slightly lower when the utilization rates of the historically 

uninsured are assumed to be half of what has been found 

in the past. The increases in physician need are slightly 

higher when utilization rates of the historically uninsured 

are assumed to be double what has been found in the past.

TABLE 23

Need for Physicians in the U.S., 2000-2020,

Alternative Scenario Two Projections:

Sensitivity Analysis

Year

Baseline

FTE

Physicians

Low Utilization/

26.5%

Reduction in

Services

FTE

Physicians

Equivalent Utilization/

26.5%

Reduction in

Services

FTE

Physicians

High Utilization/

26.5%

Reduction in

Services

FTE

Physicians

2000 781,227 574,202 574,202 574,202

2005 907,758 639,094 667,202 711,194

2010 959,036 674,837 704,891 751,792

2015 1,014,992 713,944 746,019 795,973

2020 1,073,641 755,116 789,126 842,062

% Change 37% 32% 37% 47%
SIXTEENTH REPORT OF COGME 31

TABLE 24

Need for Physicians in the U.S., 2000-2020,

Alternative Scenario Three Projections:

Changes in Utilization Rates/Increased Utilization Review

Year

Baseline

FTE

Physicians

Changing

Utilization/

Increased UR

FTE

Physicians

U.S.

Population

(1,000s)

Changing

Utilization/

Increased UR

FTEs per

100k Pop.

2000 781,227 574,202 276,241 208

2005 907,758 718,579 288,286 249

2010 959,036 827,465 300,431 275

2015 1,014,992 962,593 313,116 307

2020 1,073,641 1,120,128 325,942 344

% Change 37% 95% 18% 65%

CONCLUSIONS: NEED FOR 

PHYSICIANS IN THE U.S., 2000-2020

There is no single, generally accepted standard for the 

number of physicians needed by a community or Nation. 

One can hold up the current use of physicians in communities with above-average health status indicators and set their 

rates of utilization as a benchmark (Goodman et al 1996). 

However, the differences between communities in terms of 

health delivery systems and population needs are so significant that they raise serious questions about the relevancy of 

using the workforce in one community for other communities. Moreover, as has been pointed out in a number of studies examining the correlation between community health 

status and the size of health workforce in a community, once 

a certain size of the health workforce is achieved, it is often 

difficult to measure the associated increase or decrease in 

health status. Thus, for many communities in the Nation, 

it might appear as though the size of the health workforce 

(in this case, the physician workforce) is not correlated with 

the health status of the community. The process of selecting the most appropriate communities to use as benchmarks 

TABLE 25

Need for Physicians in the U.S., 2000-2020,

Alternative Scenario Three Projections:

Sensitivity Analysis

Year

Baseline

FTE

Physicians

Low

Utilization/

Changing

Utilization/

Increased UR

FTE

Physicians

Equivalent

Utilization/

Changing

Utilization/

Increased UR

FTE

Physicians

High

Utilization/

Changing

Utilization/

Increased UR

FTE

Physicians

2000 781,227 574,202 574,202 574,202

2005 907,758 690,471 718,579 762,570

2010 959,036 797,411 827,465 874,367

2015 1,014,992 930,518 962,593 1,012,546

2020 1,073,641 1,086,118 1,120,128 1,173,064

% Change 37% 89% 95% 104%
SIXTEENTH REPORT OF COGME 32 

would entail a great deal of additional analysis. Even then, 

this selection process would be open to criticism as biased 

and not reflecting the population of the Nation as a whole.

Therefore, for purposes of this analysis, the national 

experience has been used to compare the use of services by 

those with and those without heath insurance. The linchpin 

assumption made was that if those without health insurance 

were covered, they would use services at the same rate as 

those with health insurance. The sensitivity analyses relaxed the assumption, to some extent, which revealed the 

resultant effects on the prediction of future physician need.

The model and the alternative scenarios predicted a 

wide range of potential need for physicians in the U.S. in the 

future. The baseline model predicted an increase in need for 

physicians of 290,000 FTE physicians. The variation in the 

predictions associated with the alternative scenarios represented the results of assumptions having to do with other factors related to the need for physicians, that is, the changes in 

age-specific physician utilization rates and the identification 

and elimination of unnecessary services. It seems reasonable 

that the scenario that takes all factors into account (Alternative Scenario Three) is the most accurate way to predict future need for physicians. When all factors are taken together, 

then, the need for physicians is predicted to grow between 

300,000 and 390,000 FTE physicians between 2000 and 2020.

In sum, it is predicted that there will be a need of 

between 1,086,000 and 1,173,000, resulting in a shortage of physicians in 2020 in the range of 65,000 and 

150,000. It is noteworthy that without successful efforts to identify and eliminate unnecessary services, 

the physician supply-need gap could be much greater.
SIXTEENTH REPORT OF COGME 33

Physician Supply, Demand, and Need, 2000-2020: 

Specialty Mix Issues

17 Historical specialty mix patterns are derived from the PSM and PDM.

18 It is important to note that these generalist and non-generalist mixes do not pertain to new entrants, but rather to the overall specialty mix in the physician 

supply. Given the length of a typical career in medicine, the entrant specialty mixes needed to achieve these overall mixes would have to exceed the 

30 percent and 70 percent as well as 45 percent and 55 percent overall mixes. Currently, the new physician specialty mix approximates a 37 percent and 

63 percent mix.

19 It should also be noted that all specialty-specific differences (e.g., separation rates and activity rates) are not taken into account in any of these projections.

One goal of the current re-assessment of physician 

supply, demand, and need over the coming decades is to 

determine the appropriate specialty mix. In COGME’s 

Third Report (1992), a recommendation was made that 

one-half of all new practicing physicians be of the generalist 

variety (pediatrician, internist, family practitioner, and any 

combination). The recommendation had effects on the cohort of medical students and residents training in the 1990s 

thanks to a number of programs. The ranks of generalist 

physicians grew more rapidly than those of non-generalist 

physicians during the decade (Salsberg and Forte 2002). 

Toward the end of the 1990s, however, interest in generalist 

specialties began to wane, as the non-generalist specialties, 

once again, became more attractive to young physicians 

(Kimball 2000; AAMC 2002; Salsberg and Forte 2002).

In this section, the issue of specialty mix is addressed 

with regard to physician supply, demand, and need between 

2000 and 2020. The strategy employed to address this issue 

is one that looks at a variety of specialty mix levels in an 

attempt to describe the physician supply, demand, and need 

if those mixes were to occur. For each main outcome variable (supply, demand, and need), the numbers of generalists 

and non-generalists projected under these assumptions are 

presented: 1) of a continuation of historical specialty mix 

patterns17; 2) of a move toward more non-generalist-based 

medicine resulting in a 30 percent generalist and 70 percent 

TABLE 26

Supply of Physicians in the U.S., 2000-2020,

Baseline Specialty Projections

Year

Generalist

FTE

Physicians

NonGeneralist

FTE

Physicians

Generalist

FTEs per

100k Pop.

NonGeneralist

FTEs per

100k Pop.

2000 286,674 494,553 104 179

2005 317,203 538,013 110 187

2010 349,695 573,179 116 191

2015 378,651 600,874 121 192

2020 402,740 621,583 124 191

% Change 40% 26% 19% 7%

non-generalist physician supply; and 3) of a move toward 

more generalist-based medicine resulting in a 45 percent 

generalist and 55 percent non-generalist physician supply.18,19

The baseline numbers of physicians are those projections 

identified in the previous sections as the most likely to occur.

SUPPLY OF GENERALIST AND 

NON-GENERALIST PHYSICIANS: 

BASELINE PROJECTIONS

In Section II, “Supply of Physicians,” a combination 

of the baseline model and Alternative Scenario Three was 

identified as the most likely scenario for physician supply. 

In this scenario, both lifestyle changes among the physician 

workforce and productivity enhancements due to technological developments were considered. In terms of specialty mix, historical patterns suggest a slight move toward 

more generalist physicians (slightly less than 37 percent 

in 2000 to slightly more than 39 percent in 2020). Given 

these assumptions, Table 26 presents the supply of generalists and non-generalists in the U.S. from 2000 to 2020.

A small change in the specialty mix has a large impact 

on the relative growth rates of generalists and non-generalists 

between 2000 and 2020. If the historical patterns continue, 

generalists will grow by 116,000 FTE physicians (40 percent), 
SIXTEENTH REPORT OF COGME 34 

adding 20 FTE physicians per 100,000 population. Nongeneralists will grow by some 127,000 FTEs (26 percent), 

adding about 12 FTE physicians per 100,000 population.

Supply Specialty Mix Alternative 

Scenario One: Non-Generalist 

Dominant Mix

As mentioned at the beginning of this section, generalist 

specialties have begun to lose favor among young physicians 

and those still in training, so it is unclear whether the patterns observed in the mid-1990s will continue in the future. 

The ramifications of a move toward a more non-generalist 

mix (in terms of the supply of physicians) are explored in 

this alternative scenario. In this scenario, instead of an 

increase in the generalist specialties, the mix is weighted 

toward a non-generalist mix. Specifically, it is assumed 

that by 2020, generalists will make up just 30 percent of 

the physician supply, whereas non-generalists will make 

up 70 percent. Table 27 presents the results of this change.

The move toward a specialty mix that is more nongeneralist, dominated over the next two decades, seriously depletes the future generalist supply. Growing 

by less than 20,000 FTEs (7 percent) between 2000 and 

2020, generalist physician growth does not keep up with 

population growth. On the other hand, the non-generalist supply grows by nearly 50 percent (223,000 FTE 

physicians), continuing to outpace population growth.

TABLE 27

Supply of Physicians in the U.S., 2000-2020,

Specialty Projections:

30% Generalist/70% Non-Generalist Scenario

Year

Generalist

FTE

Physicians

NonGeneralist

FTE

Physicians

Generalist

FTEs per

100k Pop.

NonGeneralist

FTEs per

100k Pop.

2000 286,674 494,553 104 179

2005 299,509 555,706 104 193

2010 307,757 615,117 102 205

2015 310,253 669,272 99 214

2020 307,297 717,026 94 220

% Change 7% 45% –9% 23%

Supply Specialty Mix Alternative 

Scenario Two: Generalist-Weighted 

Mix

Certainly, some observers argue that the Nation 

would be better served having more generalist physicians. This scenario presents what the physician supply 

would look like if by 2020, the overall specialty mix of 

physicians approximated a 45 percent generalist and 55 

percent non-generalist mix. Table 28 presents the results.

With a move toward a more generalist-weighted specialty mix over the time period of investigation, a very 

different physician supply results. Generalists grow by 

174,000 FTE physicians (61 percent), adding about 37 

FTEs per 100,000 population. The non-generalists grow 

by about 70,000 FTE physicians (14 percent), paralleling the growth of the population through 2010. Growth 

among the non-generalist physician supply begins to fall 

behind the overall population growth, however, after 2010.

DEMAND FOR GENERALIST AND 

NON-GENERALIST PHYSICIANS: 

BASELINE PROJECTIONS

In Section III, “Future Demand for Physicians,” Alternative Scenario Two was identified as the most likely scenario 

for future demand for physicians in the U.S. In this scenario, 

the age-specific utilization rate changes observed between 
SIXTEENTH REPORT OF COGME 35

TABLE 28

Supply of Physicians in the U.S., 2000-2020,

Specialty Projections:

45% Generalist/55% Non-Generalist Scenario

Year

Generalist

FTE

Physicians

NonGeneralist

FTE

Physicians

Generalist

FTEs per

100k Pop.

NonGeneralist

FTEs per

100k Pop.

2000 286,674 494,553 104 179

2005 331,580 523,636 115 182

2010 376,972 545,901 125 182

2015 420,449 559,075 134 179

2020 460,945 563,378 141 173

% Change 61% 14% 36% –3%

1990 and 2000 were projected to continue from 2000 to 2010 

and from 2010 to 2020. In terms of specialty mix, historical 

demand patterns suggest a slight move toward more generalist physicians (slightly less than 37 percent in 2000 to slightly 

more than 37 percent in 2020). Starting from this baseline, 

and applying historical patterns of the demand for generalists 

and non-generalists, Table 29 presents the demand for generalists and non-generalists in the U.S. from 2000 to 2020.

Because of the slight change in the specialty demand 

mix, the demand for generalists and the demand for nongeneralists grow at similar rates in this scenario (44 percent 

and 41 percent, respectively). In terms of relative demand 

for physicians, demand grows from 104 generalist FTEs 

TABLE 29

Demand for Physicians in the U.S., 2000-2020,

Baseline Specialty Projections

Year

Generalist

FTE

Physicians

NonGeneralist

FTE

Physicians

Generalist

FTEs per

100k Pop.

NonGeneralist

FTEs per

100k Pop.

2000 286,674 494,553 104 179

2005 311,882 529,502 108 184

2010 339,856 577,220 113 192

2015 373,553 634,469 119 203

2020 411,935 696,981 126 214

% Change 44% 41% 22% 19%

per 100,000 population in 2000 to 126 in 2020. At the 

same time, demand for non-generalists grows from 179 

non-generalist FTEs per 100,000 to 214. Compared to the 

baseline specialty projections of supply, the Nation will experience a shortage of generalists (9,000 FTEs), as well as 

non-generalists (75,000 FTEs). If the specialty mix in the 

supply is as projected in Alternative Scenario One above, 

the shortage of generalists will be exacerbated, whereas 

the shortage of non-generalists will be eliminated, with a 

small surplus (30,000 FTEs) throughout most of the period. 

In a more generalist-weighted supply scenario (Alternative Supply Specialty Mix Scenario Two above), there is 

a surplus of generalists (49,000 FTEs) and a shortage of 

non-generalists by 2010 that grows larger through 2020.
SIXTEENTH REPORT OF COGME 36 

Demand Specialty Mix Alternative 

Scenario One: Non-Generalist 

Dominant Demand Mix

In this scenario, the demand for physicians in 2020 

is such that 30 percent of the physicians demanded are 

generalists and 70 percent are non-generalists. Generalists account for approximately 9 percent less of the total 

demand for physicians in this scenario compared to the 

baseline demand specialty mix. Non-generalists account 

for approximately 9 percent more of the total demand for 

physicians than in the baseline assumptions. Table 30 presents the demand for physicians under these assumptions.

In this scenario, demand for generalists and non-generalists grows in absolute terms through the period of interest. Demand for generalists grows at approximately the same rate as 

the population, remaining at 102 FTE physicians per 100,000 

from 2005 on, while demand for non-generalists increases 

57 percent in terms of FTEs and 33 percent in terms of FTEs 

per 100,000 population. Compared to the baseline specialty 

projections of supply, the Nation will experience a significant 

surplus of generalists (70,000 FTEs), as well as a large shortage of non-generalists (155,000 FTEs). If the specialty mix 

in the supply is as projected in Alternative Supply Specialty 

Mix Scenario One above, the surplus of generalists would be 

lessened to approximately 25,000 FTEs, and the shortage of 

non-generalists would be lessened substantially as well. In a 

more generalist-weighted supply scenario (Alternative Supply Specialty Mix Scenario Two above), there is a large surplus of generalists (128,000 FTEs). There is also a shortage 

of non-generalists by 2005 that grows larger through 2020.

Demand Specialty Mix Alternative 

Scenario Two: Generalist-Weighted 

Mix

In this scenario, the demand for physicians in 2020 is 

such that 45 percent of the physicians demanded are generalists and 55 percent are non-generalists. Compared to 

the baseline demand specialty mix, in this scenario generalists account for approximately 6 percent more of the total 

demand for physicians than in the baseline scenario. Nongeneralists account for approximately 6 percent less of the 

total demand for physicians than in the baseline. Table 31 

presents the demand for physicians under these assumptions.

In this scenario, demand for generalists and non-generalists grows in absolute terms through the period of interest. 

Demand for generalists grows at a substantial rate, moving 

from 104 FTE physicians per 100,000 in 2000 to 153 in 2020. 

Demand for non-generalists increases 23 percent in terms of 

FTEs and 5 percent in terms of FTEs per 100,000 population, 

a far slower pace than that of generalists. Compared to the 

baseline specialty projections of supply, the Nation will experience a significant shortage of generalists (97,000 FTEs), 

as well as a small surplus of non-generalists (12,000 FTEs). 

If the specialty mix in the supply is as projected in Alternative Supply Specialty Mix Scenario One above, the shortage 

of generalists will be exacerbated to approximately 192,000 

FTEs and the surplus of non-generalists will be greatly increased as well. In a more generalist-weighted supply scenario (Alternative Supply Specialty Mix Scenario Two above), 

there would be a shortage of generalists (40,000 FTEs) 

and a shortage of non-generalists (46,000 FTEs) in 2020.

TABLE 30

Demand for Physicians in the U.S., 2000-2020,

Specialty Projections:

30% Generalist/70% Non-Generalist Scenario

Year

Generalist

FTE

Physicians

NonGeneralist

FTE

Physicians

Generalist

FTEs per

100k Pop.

NonGeneralist

FTEs per

100k Pop.

2000 286,674 494,553 104 179

2005 294,665 546,719 102 190

2010 305,823 611,252 102 203

2015 319,279 688,743 102 220

2020 332,675 776,241 102 238

% Change 16% 57% –2% 33%
SIXTEENTH REPORT OF COGME 37

NEED FOR GENERALIST AND 

NON-GENERALIST PHYSICIANS

In Section IV, “Future Need for Physicians,” Alternative 

Scenario Three was identified as the most likely scenario for 

future need for physicians in the U.S. In this scenario, the 

age-specific utilization rate changes observed between 1990 

and 2000 were projected to continue from 2000 to 2010 and 

from 2010 to 2020. Further, this scenario also accounted for 

unnecessary services that would be weeded out by a strong 

utilization review process. In terms of specialty mix, historical need patterns suggest a slight move toward more generalist physicians (slightly less than 37 percent in 2000 to slightly 

more than 37 percent in 2020). Starting from this baseline, 

and applying historical patterns of the need for generalists 

and non-generalists, Table 32 presents the projected need for 

generalists and non-generalists in the U.S. from 2000 to 2020.

TABLE 31

Demand for Physicians in the U.S., 2000-2020,

Specialty Projections:

45% Generalist/55% Non-Generalist Scenario

Year

Generalist

FTE

Physicians

NonGeneralist

FTE

Physicians

Generalist

FTEs per

100k Pop.

NonGeneralist

FTEs per

100k Pop.

2000 286,674 494,553 104 179

2005 326,217 515,167 113 179

2010 374,604 542,472 125 181

2015 432,681 575,340 138 184

2020 499,012 609,904 153 187

% Change 74% 23% 48% 5%

Because of almost negligible changes in the specialty 

need mix, the demand for generalists and the demand for 

non-generalists grow at similar rates in this scenario (97 

percent and 94 percent, respectively). In terms of relative 

need for generalist physicians, need grows from 76 generalist 

FTEs per 100,000 population in 2000 to 127 generalist FTEs 

in 2020. At the same time, need for non-generalists grows 

from 132 to 216 non-generalist FTEs per 100,000. Compared 

to the baseline specialty projections of supply, the expected 

physician workforce will experience a shortage of generalists 

(13,000 FTEs), as well as non-generalists (83,000 FTEs). If 

the specialty mix in the supply is as projected in Alternative 

Supply Specialty Mix Scenario One above, the shortage of 

generalists will be greatly increased, reaching over 100,000 

FTEs by 2020. The shortage of non-generalists will be reversed, with a large initial surplus shrinking throughout the 

period. In a more generalist-weighted supply scenario (AlterTABLE 32

Need for Physicians in the U.S., 2000-2020,

Baseline Specialty Projections

Year

Generalist

FTE

Physicians

NonGeneralist

FTE

Physicians

Generalist

FTEs per

100k Pop.

NonGeneralist

FTEs per

100k Pop.

2000 210,705 363,497 76 132

2005 266,312 452,266 92 157

2010 306,667 520,799 102 173

2015 356,746 605,847 114 193

2020 415,130 704,998 127 216

% Change 97% 94% 67% 64%
SIXTEENTH REPORT OF COGME 38 

native Supply Specialty Mix Scenario Two above), there is a 

surplus of generalists (35,000 FTEs). There is also a shortage 

of non-generalists by 2010 that grows larger through 2020.

Need Specialty Mix Alternative 

Scenario One: Non-Generalist 

Dominant Need Mix

In this scenario, the need for physicians in 2020 is such that 

30 percent of the physician need is associated with generalist 

services and 70 percent with non-generalist services. Compared to the baseline demand specialty mix, in this scenario 

generalists account for approximately 9 percent less of the total need for physicians than in the baseline scenario. Non-generalists account for approximately 9 percent more of the total 

need for physicians than in the baseline assumptions. Table 

33 presents the need for physicians under these assumptions.

In this scenario, the need for generalists and non-generalists grows in absolute terms throughout the period of interest. The need for generalists grows at a higher rate than the 

population, increasing from 76 FTE physicians per 100,000 

in 2000 to 103 FTE physicians per 100,000 in 2020. The 

need for non-generalists grows dramatically, increasing 116 

percent in terms of FTEs and 83 percent in terms of FTEs 

per 100,000 population. Compared to the baseline specialty 

projections of supply, under this need scenario the expected 

physician workforce will experience a significant surplus 

of generalists (66,000 FTEs), as well as a large shortage of 

non-generalists (163,000 FTEs). If the specialty mix in the 

supply is as projected in Alternative Supply Specialty Mix 

Scenario One above, the surplus of generalists would be reversed and a shortage of 29,000 FTE generalists would result. 

The shortage of non-generalists would be lessened substantially to approximately 67,000 FTEs. In a more generalistweighted supply scenario (Alternative Supply Specialty Mix 

Scenario Two above), there is a large surplus of generalists 

(124,000 FTEs). There is also a shortage of non-generalists by 2010 that grows significantly larger through 2020.

Need Specialty Mix Alternative 

Scenario Two: Generalist-Weighted 

Mix

In this scenario, the demand for physicians in 2020 

is such that 45 percent of the physician need is associated 

with generalists and 55 percent with non-generalists. Compared to the baseline need specialty mix, in this scenario 

generalists account for approximately 6 percent more of 

the total need for physicians than in the baseline scenario. 

Non-generalists account for approximately 6 percent less of 

the total need for physicians than in the baseline. Table 34 

presents the demand for physicians under these assumptions.

In this scenario, the need for generalists and non-generalists grows in absolute terms through the period of interest. 

The need for generalists grows at a substantial rate, moving 

from 76 FTE physicians per 100,000 in 2000 to 155 FTE 

physicians per 100,000 in 2020. The need for non-generalists 

increases 69 percent in terms of FTEs and 44 percent in terms 

of FTEs per 100,000 population, a far slower pace than that of 

generalists (103 percent). Compared to the baseline specialty 

projections of supply, the expected physician workforce will 

experience a significant shortage of generalists (102,000 

FTEs), as well as a small surplus of non-generalists (5,000 

FTEs). If the specialty mix in the supply were as projected 

in Alternative Supply Specialty Mix Scenario One above, the 

shortage of generalists would be exacerbated to approximately 197,000 FTEs and the surplus of non-generalists would 

also be greatly increased. In a more generalist-weighted supply scenario (Alternative Supply Specialty Mix Scenario Two 

above), there would be a shortage of generalists (44,000 FTEs) 

and a shortage of non-generalists (53,000 FTEs) in 2020.
SIXTEENTH REPORT OF COGME 39

TABLE 33

Need for Physicians in the U.S., 2000-2020,

Specialty Projections:

30% Generalist/70% Non-Generalist Scenario

Year

Generalist

FTE

Physicians

NonGeneralist

FTE

Physicians

Generalist

FTEs per

100k Pop.

NonGeneralist

FTEs per

100k Pop.

2000 210,705 363,497 76 132

2005 251,657 466,922 87 162

2010 275,940 551,525 92 184

2015 304,890 657,703 97 210

2020 336,039 784,090 103 241

% Change 59% 116% 35% 83%

TABLE 34

Need for Physicians in the U.S., 2000-2020,

Specialty Projections:

45% Generalist/55% Non-Generalist Scenario

Year

Generalist

FTE

Physicians

NonGeneralist

FTE

Physicians

Generalist

FTEs per

100k Pop.

NonGeneralist

FTEs per

100k Pop.

2000 210,705 363,497 76 132

2005 278,604 439,975 97 153

2010 338,000 489,465 113 163

2015 413,182 549,411 132 175

2020 504,058 616,071 155 189

% Change 139% 69% 103% 44%
SIXTEENTH REPORT OF COGME 40 
SIXTEENTH REPORT OF COGME 41

Issues Beyond the Models

PAs (e.g., the existing supply of physicians is able to serve 

additional patients because of the presence of NPs and PAs). 

However, data are not currently available on the magnitude 

of the enhancement of physician supply afforded by NPs and 

PAs, that is, how many additional patients a physician can see 

if an NP or PA is added to a practice. It is also likely that some 

additional visits to a practice with an NP or PA may reflect an 

enhancement of services as well as an increase in productivity.

In the models presented above, NPs and PAs and 

other NPCs are accounted for at historical levels of practice. Further, all models assume a fixed ratio of these 

practitioners-to-physician in the future. However, the 

supplies of NPs and PAs are growing more rapidly than 

the supply of physicians; thus, the ratio is actually increasing. As a result, it is likely, all else being equal, that the 

number of services provided in the future will be greater in 

the future because of the relative increase in NPs and PAs.

The number of practicing PAs, NPs, and Certified Nurse 

Midwives (CNMs) per 100 patient care physicians was approximately 16 in 2000, about 1 for every 6 physicians. 

If the number of NPs, PAs, and CNMs rises between 2000 

and 2020 at the current rate of growth, then about 150,000 

new PAs, NPs, and CNMs would be available to provide services to the Nation. This magnitude of increase on the supply 

of PAs, NPs, and CNMs would increase the ratio of these 

practitioners to physicians. The ramifications of an increase 

in this ratio for the supply of physicians in the U.S. and the 

provision of services are excellent topics for future research.

BOUTIQUE MEDICINE

A recent development has been the establishment of physician practices confined to a few hundred patients. To join a 

practice of this type, often referred to as “boutique medicine,” 

patients usually have to pay a substantial annual fee. Reports 

on these practices indicate that physicians find them rewarding 

because they can focus on and provide individualized service 

to patients enrolled in their practice. The attraction to patients 

who enroll is that they receive individualized attention by a 

physician who knows them well and is very available. Given 

the cost to the patient, it is unlikely that this type of practice 

will become a very common model; however, there may be 

some interesting implications for the physician workforce.

Given the very limited number of patients per physician, 

a relatively small percent of the population could occupy a far 

greater share of the generalist physician workforce. It is also 

not clear what the impact would be on the use of such physicians in non-generalist specialties. Conceptually, the availability of a personal physician may lead to an increased role 

RESIDENT AND FELLOW 

WORK-HOUR RESTRICTIONS

All models presented above make no distinction between physicians in training 

(residents and fellows) and physicians who have completed 

their graduate medical training. As such, historical patterns of practice (e.g., work hours) are incorporated into the 

models and their projections. Thus, the recent implementation of regulations limiting resident and fellow work hours 

to 80 or fewer has not been taken into account. Although 

the general impact of these regulations is clear; that is, the 

total supply of physicians (FTEs) will decrease. It is unclear what the magnitude of the effect will be. It is also 

unclear how much of the reduced hours per week will be 

taken away from patient care versus educational activities. 

It is also possible that reduced work hours during training 

and increased flexibility in scheduling will contribute to 

such changes as increased job sharing and reduced patient 

care hours in physicians’ practice patterns after training.

NON-PHYSICIAN CLINICIANS (NPCs)

Over the past 30 years, NPCs have become increasingly prominent in the health care field. This group, which 

includes nurse practitioners (NPs), advance practice nurses, 

physician assistants (PAs), chiropractors, acupuncturists, 

naturopaths, optometrists, podiatrists, and others, doubled 

in size between 1992 and 1997. The supply of NPs, PAs, 

and midwives tripled between 1990 and 2000 and is likely 

to nearly double between 2000 and 2020. In addition to 

their expanding number, the scope of practice and ability 

of NPCs to receive insurance reimbursement have been increasing slowly but steadily over the years (Wing et al 2003).

Although there has been some tension between physicians and NPCs, for the most part, these clinicians have 

been accepted by both the physician community and patients. It has also been suggested that as the number of 

NPCs grow, they will be more able to alter their practice 

environments (e.g., gain increased independence from 

physicians) and to compete with physicians (Cooper 

1998). In the final analysis, the net effect of the presence of NPCs is the same: the supply of practitioners 

available to provide services to patients will be increased.

Given their growing numbers and their scope of practice, 

NPs and PAs are of particular importance in calculating the 

supply and demand for physicians. Since all PAs work under 

the supervision of physicians and almost all NPs work in 

collaboration with physicians, it is clear that the supply of 

physicians is increased by the growing number of NPs and 
SIXTEENTH REPORT OF COGME 42 

for the physician and could reduce demand for specialists. In 

some ways, boutique medicine may be a new approach to personalized care provided by the general physician of the past.

Further research on boutique medicine, including research on patient and physician satisfaction and the use of services, appears warranted.
SIXTEENTH REPORT OF COGME 43

Conclusions: Physician Supply, Demand, and Need 

in the U.S., 2000-2020

Many of the models and scenarios developed for 

this report have been described previously. The goal of 

this section is to describe a predicted range for the levels 

of physician supply, demand, and need. (Figure 9 shows 

these levels.) Thus far, no one scenario has provided 

predictions that could be considered absolutely correct. 

However, the sensitivity analyses clarified the importance of the particular assumptions made in each scenario.

SUPPLY

The baseline supply model predicted that by 2020 about 

972,000 FTE physicians would be in the physician supply. 

The alternative scenarios showed how this baseline prediction could be lowered or increased based on the lifestyle differences among newer physicians and likely developments 

to enhance the productivity level of physicians. Although 

lifestyle concerns will eventually affect all physicians, during the period of investigation (2000 to 2020) only a portion 

of the physician supply will be affected. On the other hand, 

it is unclear how or when the potential productivity enhancements will begin to affect the physician supply. It is certain 

that these enhancements will occur, through technology developments or through help from NPCs. Given that reasoning, it is predicted that in 2020 the supply of physicians will 

be in the range of 972,000 and 1,077,000 FTE physicians.

DEMAND

The baseline demand model predicted that by 2020 demand for physicians in the U.S. would be about 988,000 FTE 

physicians. The alternative scenarios showed this baseline 

prediction could be lowered or increased based on assumptions about the effects of economic expansion, the changes in 

age-specific physician utilization rates, and the elimination 

of unnecessary services through rigorous utilization review. 

As proponents of the perspective admit, no safe ways currently exist to identify and eliminate unnecessary services. 

As a result, it is unlikely that demand for physicians will 

experience declines of the magnitude predicted by the 

models assuming that unnecessary services are eliminated.

On the other hand, the U.S. economy is likely to 

continue to expand at a higher rate than has been assumed in most models presented in this report. However, it has not been decided whether there is, in fact, a 

causal relationship between economic growth and demand 

FIGURE 9

Physician Supply, Demand, and Need in the U.S., 2020

1,400,000

1,350,000

1,300,000

1,250,000

1,200,000

1,150,000

1,100,000

1,050,000

1,000,000

950,000

900,000

850,000

800,000

Supply Demand Need

1,076,000

972,000

1,240,000

1,027,000

1,173,000

1,086,000
SIXTEENTH REPORT OF COGME 44 

for physicians; the correlation between the two may be 

spurious. Certainly, more investigation is warranted.

Finally, age-specific physician utilization rates are increasing among the population above 45 years of age (and 

declining for those under age 45) at the same time that the 

population above age 45 is growing. Certain groups are 

growing at higher rates (e.g., the 65 years of age and older 

group). Although many have commented on the effect of 

the aging of the U.S. population, the changes in physician 

utilization rates have gone unnoticed. The added effects of 

these changing rates have been shown in several alternative scenarios in this report. Further changes in these rates 

should be monitored, but historical trends suggest that the 

changes modeled in the alternative scenarios presented in 

this report are reasonable. Thus, it is predicted that the 

demand for physicians in 2020 will require the equivalent of between 1,027,000 and 1,240,000 FTE physicians.

NEED

As difficult as need is to define, need has been conceptualized as equivalent to what physician utilization would be 

if the entire population of the U.S. were insured and utilized 

services in a manner similar to the historically insured population. Employing this conceptualization, the forecasting 

models predict that the need for physicians in the U.S. in 2020 

will be about 1,075,000 FTE physicians. Under some alternative assumptions, the need for physicians was shown to be 

higher (if age-specific utilization rates are taken into account) 

or lower (if utilization review rigorously identified and eliminated unnecessary services). Even though a low probability 

of utilization review exists as it is currently performed to identify and eliminate unnecessary services completely, estimates 

of need should take into account that those services are, indeed, unneeded. Thus, it is predicted that physician need will 

be in the range of 1,086,000 and 1,173,000 FTE physicians.

SUMMARY

In sum, when the midpoint of the predicted range of supply and demand is used, the Nation is likely to face a shortage 

of about 85,000 FTE physicians in 2020. When the midpoint 

of the predicted range of supply and need is used, the Nation is 

also likely to face a shortage of about 96,000 physicians in 2020.
SIXTEENTH REPORT OF COGME 45

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