The critical care medicine crisis: a call for federal action : a white paper from the critical care professional societies

In the United States, shortages of qualified health-care professionals have created a major threat to the availability and quality of critical care services for seriously ill patients. An unprecedented, and largely unrecognized, shortage of physician intensivists in the near future will deny standard critical care services for large populations of patients with serious illnesses. If the current trend persists, shortages of these specialists, combined with the current shortages of critical care nurses, pharmacists, and respiratory therapists, will become severe by 2007 and will worsen through 2030. Numerous studies demonstrate that critical care services directed by physicians who are formally trained in critical care medicine reduce mortality in the ICU and reduce health-care costs. While people of all ages, from low-birth-weight newborns to senior citizens, benefit from treatment in the ICU, older Americans receive a disproportionate share of ICU services. The demand for ICU services, therefore, will continue to grow as the baby boom generation ages. To address the shortage, the critical care professional societies recommend that steps be taken to improve the efficiency of critical care providers, to increase the number of critical care providers, and to address the demand for critical care services.

Key words: critical care; workforce shortage

Abbreviations: CMS = Centers for Medicare and Medicaid Services; COMPACCS = Committee on Manpower for Pulmonary and Critical Care Societies; FOCCUS = Framing Options for Critical Care in the United States; GME = graduate medical education; HRSA = Health Resources and Services Administration

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I. ISSUE OVERVIEW

A. General Background on Critical Care Medicine

Critical care medicine is the direct delivery of medical care by a physician to a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. Care of these patients can take place anywhere in the inpatient hospital setting, although it typically occurs in the ICU. Critical care involves highly complex decision making to assess, manipulate, and support vital system functions, to treat single or multiple vital organ system failure, and/or to prevent further life-threatening deterioration of the patient's condition. (1)

Critical care medicine is provided by physician-directed multidisciplinary teams consisting of nurses, respiratory therapists, pharmacists, and physician assistants. Critical care medicine has evolved into a board-certified medical subspecialty that trains physicians to utilize a unique combination of skills needed to care for critically ill patients. Board-certified critical care specialists come from a variety of specialty backgrounds. Most of the physicians who practice critical care come from the internal medicine subspecialty of pulmonology. Other specialties that also practice critical care include anesthesiology, surgery, and pediatrics.

Numerous studies (2) have shown that board-certified critical care-directed teams save lives and reduce costs. The strength of these studies is so compelling that organizations such as the LeapFrog Group, a business consortium that studies ways to reduce health-care costs for employers, have required hospitals in their health networks to provide coverage in the ICU 24 h per day/7 days per week with board-certified critical care specialist staffing during daytime hours, and at other times with the return of ICU pages by a board-certified physician, or an arrangement for a specially trained physician or physician extender to reach an ICU patient within 5 min. (3)

While people of all ages, from low-birth weight newborns to senior citizens, receive treatment for critical care services across the United States, older Americans continue to consume a disproportionate share of critical care resources.

B. Shortage of Critical Care Providers

The United States is currently facing an unprecedented, and largely unrecognized, shortage of physicians trained to provide critical care services. As described in a study by the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS), (4) future demand for critical care services in the United States will soon exceed the capabilities of the current delivery system. The most alarming problem is that the anticipated shortage of health-care professionals practicing critical care medicine already has begun.

Today, board-certified critical care physician-directed ICU teams care for only one in three patients in the ICU. The aging population, and the coinciding increased demand for critical care services, will exacerbate the situation. If current trends continue, a severe shortage of critical care specialists will occur by 2007 and will worsen until 2030. This means that in the near future, patients with critical care illnesses will be unable to get medical treatment from physicians trained in providing critical care services.

C. Contributing Factors to the Critical Care Shortage

There are several contributing factors that have created the critical care shortage. The following factors should guide any federal policy decisions: the aging of the US population will lead to a predictable increase in the demand for critical care services; the supply of physicians and allied health professionals trained to provide critical care services will remain constant; the limited number of physician residency/ fellowship trainee slots prevents medical schools from quickly increasing the number of physicians trained in critical care medicine; cuts in graduate medical education (GME) payments have reduced the funds available for physician training; the cost of medical school education is significant and continues to rise; medical school debt pressures many physicians to pursue the highest paying specialties; and, finally, the complexity of Medicare reimbursement tends to drive physicians out of the field.

The combination of these factors creates the self-fulfilling prophecy of a depleted workforce. Because there are fewer critical care specialists, those remaining become overwhelmed and exit the system prematurely.

There are many challenges facing critical care providers. Considering the intensity of services, and the time commitment and emotional demands involved, the reimbursement for critical care medicine is low. Further complicating the problem is that many critical care practices are finding it difficult to hire new physicians and critical care nurses from a diminishing pool of qualified applicants. While the need for additional critical services many be growing, critical care physicians are prevented from significantly increasing their critical care time because of other clinical and business commitments.

II. FEDERAL POLICY RECOMMENDATIONS

Policy initiatives can be implemented to address the looming shortage of physicians trained in critical care medicine. Some of these initiatives are specific to critical care medicine, and others will affect the entire field of medicine. Federal support is required to implement many of these initiatives.

The following sections outline a series of policy initiatives that have been identified by the COMPACCS as key actions with which to address the craning shortage of critical care providers. These initiatives cover the following three general areas: improving the efficiency of critical care providers; increasing the supply of critical care providers; and addressing patient demand for critical care services.

A. Improving the Efficiency of Critical Care Providers

1. Implement the Framing Options for Critical Care in the United States Recommendations: In response to the COMPACCS study, the professional societies for critical care nurses and physicians organized a task force called Framing Options for Critical Care in the United States (FOCCUS), which assessed the current state of critical care and developed recommendations on how to respond to this workforce crisis.

The implementation of a number of the FOCCUS task force recommendations could be facilitated by federal government assistance, including the following: standardization of the practice of critical care (recommendation 1); examination of the role of medical informatics (recommendation 2); and research to better identify the optimal roles for critical care professionals in the delivery of services (recommendation 4).

To implement the recommendations of the FOCCUS task force, we recommend the following:

* The Agency for Health Research and Quality and the Health Resources and Services Administration (HRSA) should conduct studies on medical informatics, quality of care, and medical practice in the field of critical care medicine.

* HRSA should conduct studies tracking the supply of and demand for critical care services, and their utilization.