Where Have All the Cardiologists Gone?
Every day for the next 19 years, 10,000 baby boomers will reach age 65, according to the Pew Research Center. By 2030, all members of the baby boomer generation, which encompasses 26 percent of the U.S. population, will be 65 or older at a time when physicians may be in short supply. Nearly 80 percent of seniors have at least one chronic health condition, such as hypertension or heart disease, and 50 percent have at least two, according to U.S. Census data. What are the implications of this aging population and how will the dwindling number of cardiologists keep up with this demand?

Facts, figures & driving forces

Each year, cardiovascular disease strikes 1 to 2 percent of the U.S. population, and according to 2009 data from the American College of Cardiology (ACC), this trend will continue over the next two decades. While clinicians have worked to slash cardiovascular mortality, the ACC Board of Trustees Workforce Task Force has estimated that deaths from heart disease will increase 128.5 percent between 2000 and 2050.  

But will there be enough cardiologists to serve them? Fifteen percent of C-suite and cardiovascular professionals surveyed by the ACC in March said that recruiting cardiologists and other  professionals was one of the biggest hurdles. And a 2010 survey by MedAxiom showed that cardiologists saw an uptick in the number of new patients. On average, cardiologists reported seeing 349 new patients in 2009 alone. To deal with this spike, the number of cardiologists must double.

“The workforce shortage has built up over time,” says Suzette Jaskie, MBA, president and CEO of MedAxiom Consulting in Neptune Beach, Fla. “We now have a large number of cardiologists in their late 50s and older hitting retirement age, which could eventually perpetuate this shortage.” In fact, it has been estimated that 10 percent of cardiologists will retire in the next 10 years.

Fellowship programs for interventional cardiologists and general cardiologists are also few and far between, Jaskie says. “We are not taking in as many cardiologists and we also have had a big drop-off in interventional volumes.” This, combined with the economic downturn and cardiologists working longer, leaves few openings for younger cardiologists. “We will see some real issues as cardiologists begin to reach retirement age,” Jaskie says.  

In 2009, the ACC’s Workforce Task Force issued a survey about potential workforce challenges and outlined strategies to thwart this deficit. Many open cardiologist positions were left unfilled, says George P. Rodgers, MD, cardiologist at the Seton Heart Institute in Austin, Texas, and ACC Workforce Task Force committee member. There were 1,685 open positions for general cardiologists, 660 open positions for electrophysiologists and 1,941 open positions for interventionalists.

Many independent cardiologists may be “skittish on taking on more mouths to feed,” due to the dwindling economy and reimbursement cuts, says Rodgers. “Hiring has decreased, yet there is still a demand. This will eventually become unsustainable.”   

The healthcare reform bill also could perpetuate this shortage, he says. “If those without insurance are insured, it will increase the demand for cardiovascular services,” says Rodgers. However, accountable care organizations (ACOs) could alleviate this problem through attempts to divvy up resources more efficiently. In addition, the ACO focuses on quality and outcomes rather than procedures performed. “You get what you incentivize,” Rodgers says. “If you incentivize quality outcomes, then that’s what you will get, but if you incentivize a lot of procedures, it will result in more procedures.”

Feast or famine

Joseph E. Marine, MD, director of arrhythmia services at the Johns Hopkins Bayview Medical Center in Baltimore, challenged the conclusions of the ACC’s task force in a 2010 letter to the editor when he questioned whether cardiologists are actually in a shortage, or a surplus. He says the task force may have failed to examine whether there is a surplus of specialists, which may ultimately drive “excessive” healthcare spending (J Am Coll Cardiol 2010;55:838-839).

He referenced a Dartmouth Atlas of Health Care project brief, published in 2009, that assessed physician capacity and workforce variations in the U.S. The brief found that physician workforce varied by region—sometimes by as much as 300 percent. San Francisco, for example, had more than 100 primary care physicians (PCPs) per 100,000 residents, while five regions in Texas had fewer than 50 PCPs per 100,000 residents. These data suggest that the U.S. would have lower costs without significant impact on quality of care or patient access with a lower overall concentration of specialists.

“Healthcare tends to be a local market,” Marine says, adding that the ACC task force also did not factor public concern about overutilization. Validation of reports about a lack of adherence to guidelines and concerns about unnecessary testing may prompt “more pressure on the cardiovascular community to reduce this perceived overuse and we may then see utilization of specialists go down, rather than up.”

Top Workforce & Fiscal Challenges

In a just-released survey, hospital administrators identified recruiting cardiovascular (CV) staff and reimbursement as among the biggest challenges to operating a CV business line. Question: What have been the toughest challenges in terms of operating your cardiovascular service lines?

C-Suite  CV Professional
Source: American College of Cardiology
Top Workforce & Fiscal Challenges - 90.83 Kb

Future trends

“We are telling practices to have a formulized acquisition and succession plan,” Jaskie says. Practices must ensure that they first have a stable workforce before they can boost recruitment for new cardiologists.

However, hospitals must be careful, says Jaskie. “You don’t want to bring in four or five new doctors all at the same time.” Newer cardiologists may need more mentoring than established doctors.

The ACC is going a step further and attempting to shorten the track to become a cardiologist. Currently, after medical school, a fellow does three years of internal medicine, three years of cardiology and would tack on another one or two years for a specialty. ACC’s goal is to shorten the track from six years to five years. A five-year pilot program will be rolled out in four of the 179 fellowship programs over the next year, says Rodgers.  

While the ACC task force says the healthcare system must trend toward increasing the supply of cardiovascular specialists, Goodman and Fisher in a 2008 perspective wrote that the presence of more physicians would not translate into better care, and increasing the number of physicians could raise healthcare spending even more (N Engl J Med 2008;358:1658-1661). They summed that “increasing the number of physicians will make our healthcare system worse, not better.” The authors estimated the additional costs of training new physicians to expand the workforce by 30 percent would equate to approximately $5 billion to $10 billion per year.

“Studies suggest that the more specialists you have in a specific region, the higher global healthcare costs, even though competition may drive down individual unit costs of services,” Marine says.

While cardiovascular mortality is down, patients in need are on the rise. But Marine says having more elderly patients with cardiovascular disease does not necessarily require more electrophysiologists or interventionalists; instead, it may call for more geriatricians who specialize in cardiology.

Shifts in the economy and medical trends point to the current worsening dilemma—more patients needing specialty care. If the gap between supply and demand remains large, patients may soon face limited access to specialty care by cardiologists.