The Medical Education Futures Study Blog

Recently I’ve heard arguments suggesting Medicare should increase the number of funded graduate medical education (GME) positions because as U.S. medical schools expand, U.S. medical graduates will no longer get into their chosen residency positions.  This sentiment is often echoed in medical student blogs and chat rooms, with students arguing that there aren’t enough of specific specialty residency positions.

But these arguments beg the question – what demand are we meeting through our federal support of GME?

Supply and demand is a basic tenet of a marketplace economy and it is a concept that Americans generally believe in.  In this situation supply is the number of GME positions, but what demand are we meeting?  Certainly there is a demand generated by medical students for certain kinds of residency positions.  But is Medicare paying hospitals an average of $90k per resident to meet medical student demand for choice residency positions?

Or is demand that of hospitals for cheap labor?  An interesting research study came out this week indicating hospitals are favoring specialty GME positions over primary care positions, with a resultant shift in Medicare funding supporting more specialty training over primary care training.  Hospitals, as a result, are essentially getting a larger workforce for the health care services that are the most highly reimbursed and Medicare is subsidizing the staffing demands of hospitals to increase the provision of costly high intensity, specialty care.

What demand is Medicare meeting through its support of graduate medical education?  I would suggest the demand we should be meeting is that of the nation for the number and kinds of physicians that will produce the most cost-effective, high quality, accessible health care system.

Our country is mired in a physician workforce crisis with more than 56 million Americans lacking access to a primary care physician. Coverage expansion efforts in Massachusetts, a state boasting the strongest primary care workforce in the nation, exposed gaping holes in primary care networks. Current projections suggest a shortage of more than 40,000 primary care providers by 2025.

Recently key Democratic Senators led by Bill Nelson (D-FL) have introduced an amendment (SA 2909) to revive previously abandoned efforts to lift the Medicare graduate medical education (GME) “cap” as part of comprehensive health care reform legislation. The cap, adopted as part of the Balanced Budget Act of 1997, was instituted to control the quickly escalating costs of GME. By restricting the ability of teaching hospitals to receive funding for additional residency “slots,”, the number of trainees eligible for Medicare payments for most programs was fixed at 1996 levels. Thirteen years later, in the face of a dire shortage of primary care physicians, lifting the cap would seem to be an obvious answer to a daunting workforce supply problem.

The answer to the primary care shortage is not, however, lifting the GME cap - and especially not with a distribution scheme modeled after Sen. Nelson’s Resident Physician Shortage Act of 2009 (S. 973). As previously argued, this bill contains pro-primary care language camouflaging a clandestine specialty-driven agenda. Much like the redistribution of unused cap in the Medicare Modernization Act of 2003, residency positions would be allocated according to malleable preference criteria with the Centers for Medicare and Medicaid Services (CMS) afforded significant discretion to determine which institutions are awarded additional slots. It is particularly concerning that one-third of new slots would be “set aside” for current “overcap” programs. According to data from Salsberg et al, an overwhelming majority of recent position increases have been subspecialty trainees. Further, it is important to note that the number of first year residency (PGY1) positions each year (~26,000) far exceeds the number of U.S. medical graduates (~21,000). Any true increase in residency positions thus necessarily confers a 1:1 increase in the number of international medical graduates (IMGs) training in American teaching hospitals; the devastating consequences of brain-drain on source countries has been well documented. At the current growth rate of medical school class sizes, it will take at least a decade to close the graduate-resident gap.

The primary driving force behind lifting the cap is the Association of American Medical Colleges (AAMC) and specialty-professional organizations. While academic medical centers serve an essential function in our post-graduate medical education system, ignoring their contribution to steepening the cost curve and perpetuating the primary care access crisis would be myopic. By educating young physicians among the sickest and most complex patients in the country, academic medical centers perpetuate an implicit hierarchy that, compounded by pay disparities pervasive throughout medicine, incentivizes specialty training and oppresses primary care. From 1998 to 2007, the number of internal medicine residents interested in careers in primary care declined from 54 percent to 23 percent. We must reverse this trend. But the solution to our primary care crisis, despite insistence by the AAMC to the contrary, is not to arm specialty strongholds with more residency slots and the flexibility to deploy these spots to the detriment of primary care. Instead, it is time for us to engage in an earnest dialogue around restructuring our system of graduate medical education by infusing accountability to the populations and communities that residency programs are tasked with training physicians to serve. Guidance, accountability and performance standards for the generous federal Medicare GME funds teaching hospitals receive must be central to this culture shift.

Responding to this need, health care reform legislation in Senate calls for a Workforce Commission to collect and analyze data and develop recommendations therein to build a comprehensive, evidence-based strategy to revolutionize residency training and our physician workforce. We must recognize that however attractive lifting the cap may seem at face value, it will undermine larger reform goals and continue to suppress primary care in this country, crippling efforts to expand coverage and access to all Americans. Instead, we should invest in more innovative approaches starting with tackling the primary care-specialty pay gap, fully funding teaching health centers, expanding fiscal incentives for primary care such as loan-repayment and tuition reduction, and coupling of Medicare GME expansion with U.S. medical graduate class sizes.

Elizabeth Wiley, JD, MPH
National Student Life Coordinator, American Medical Student Association
MS II, The George Washington University School of Medicine

Iyah Romm
National Co-Chair, Health Care for All Steering Committee, American Medical Student Association
MS II, Boston University School of Medicine

Last month I wrote about our country’s specialty focused culture and last week as I listened to a medical student describe his cardiology rotation - how the cardiologist showed off his tools as if they were toys – and I watched as the medical student’s eyes lit up describing his experience, I realized it’s time to write about the specialty culture of medical education.  And while it would be easy to write about how medical schools and teaching hospitals, due to funding streams and priorities, have created a specialty focused culture in which medical students are subjected to comments like, “You’re too smart to go into primary care,” I’d like to talk about the need for primary care doctors to do a better job marketing themselves.

First, I’d like to address the issue of being “too smart to go into primary care.”  To get at this issue, I think it’s worthwhile to examine why physicians spend so long in training and studying things like pathophysiology or pharmacology.  Ultimately, what this training does is build brain power.  The most difficult thing that a physician does is to take a constellation of patients’ symptoms, ask the critical questions, order the key tests to figure out what the problem is and treat the patient using the best interventions.  This is at the core of a primary care physician’s job.  Procedures can be done by technicians, but accurate diagnosis and appropriate treatment are the most important and difficult parts of any physician’s job.

The second piece at the core of being a primary care physician is relationships.  Patients benefit from this relationship by receiving more consistent, coordinated and preventative care.  But as physicians, we also benefit.  Patients allow us into their lives, into their families, and whether we experience moments of heartbreak or moments of joy, it’s a privilege and a rare opportunity in society.  As a pediatrician, I look at children, remember when I held them as babies and can’t believe that they’re telling me about what they’re doing in school.  I get to share in the joy of my teenagers when they talk about which colleges they’re interested in.  And sometimes, all I can do is put my arm around a parent when I have bad news for them and assure them that we’ll move forward as partners.

Brain power and relationships – this is what being a primary care doctor is all about.  And this is what we need to help medical students see and understand.  As I mentioned last month, there are a number of factors that affect medical students’ career decisions – payment, practice, culture – but if we can do a better job showing medical students the joys of primary care, then we will be better poised to take advantage of other reforms.  And ultimately we’ll get the brightest and most compassionate students entering primary care.

I have a friend who buys a new cell phone every few months so that he always has the newest technology.  At home, I have a high definition LCD television with a DVD player and a Wii console attached.  What got me thinking about this?  A statement I overheard today regarding health care –

The U.S. doesn’t focus on health care equity because we are so focused on promoting our state of the art technology.

In fact, this appears to be true despite health care.  Our culture is focused on the newest and the most advanced technologies, whether that technology is related to our health or to our cell phones.  And in general we have the expendable income to change cell phones every few months and buy the newest, flattest television.  A new study from Canada suggests we treat health care similarly.  The study found that higher educational attainment is associated with more specialty visits and bypassing of primary care.

But the question is – is this the right way to approach health care?  Studies suggest the answer is no.  Large scale analyses of Medicare beneficiary data, done by the Dartmouth Atlas and repeated by the GAO, show utilization of physician services varies widely by location and the GAO found –

Potentially overserved and other areas are similar in demographic characteristics and the capacity to provide health care services.  The two groups are also similar in Medicare beneficiary satisfaction with health care.  In contrast, certain types of physician services, such as advanced imaging and minor procedures, are performed more frequently in potentially overserved areas relative to other areas.

The Dartmouth group explicitly connects high service (and therefore high cost) areas to the greater use of specialists and inpatient services.  Yet both seem to agree that outcomes are similar.  Another study looking at treatment of back pain finds that outcomes are similar whether you go to a primary care practitioner or orthopedic surgeon.  However, costs are significantly different – on average a primary care provider costs 30% less than an orthopedic surgeon, and this cost doesn’t take into account the cost to the patient in terms of unnecessary imaging and office visits.

The GAO suggests that “potentially overserved areas” use more services due to differences in physician practice patterns.  And there likely are differences in practice patterns between regions, but patient preferences and practices, such as bypassing primary care providers, affect physician practices.  We have a technology focused culture which translates into a specialty focused culture when accessing health care.  But this culture doesn’t translate into a high quality and efficient health care system.

Primary care is struggling for many reasons - payment disparity, demanding lifestyle, lack of practice support, an education system which favors hospital-based specialty care - but the technology culture can’t be ignored. Patients make decisions before they ever reach a doctor.

So YES - we need to change physician practices and we need to make primary care more desirable, and we also need to change our American specialty focused culture.

We can continue to buy the newest cell phones and the clearest televisions, but when it comes to health care, we’re no longer getting a good deal.  It’s time, as consumers, to choose a system that gives us the best outcomes and not just the system that is the newest and the shiniest.

Yesterday evening, the Teaching Health Centers (THC) language in the Senate Finance Chairman’s Mark came under fire due to jurisdictional issues.  Senator Enzi (R-WY) argued the portion of the language that would provide start-up grants to new THC residency programs or expanding existing programs infringed on the jurisdiction of the HELP committee.  Senator Bingaman (D-NM) argued for the importance of THCs and that the legislation had been approved by the HELP Committee.  In the end, Senator Enzi withdrew his amendment.  Despite the amendment to strike, Senator Enzi specifically stated he has “no problem” with the substance of the legislation and Senator Baucus called the THCs a “very good program.”

Watch Senator Bingaman’s argument for THCs:

Amidst the debates on insurance market reforms, Medicaid expansion, and maintaining benefits for Medicare beneficiaries, graduate medical education is getting attention in this round of health care reform legislation.  And we’ve created a crib sheet of the Senate Finance legislation:

Chairman’s Mark (9-16-09)

• Redistributes 80% of unused resident slots.  Hospitals must 1) maintain its number of primary care residents and 2) 75% of positions must be in primary care or general surgery.  The Secretary would take into account the likelihood that a hospital would 1) fill the positions in the first 3 years, 2) take part in innovative delivery models, and 3) have a rural training track.  The Secretary would distribute based on 1) hospitals in states with resident to population ratios in the lowest quartile, 2) hospitals in the top 25 states in terms of ration of population living in a HPSA and 3) hospitals in rural areas.  Limit per hospital is 75 FTE positions.  IME would be paid at 50% of current IME.
• “All or substantially all costs” previously defined as 90% of resident stipends and fringe benefits and costs associated with a supervising physician, in terms of the costs that must be incurred by a hospital training in a non-hospital setting is changed to mean only the costs of the resident stipends and fringe benefits during the time spent in that setting.
• Countable FTE - when calculating DGME certain non-patient activities in non-hospital settings will be included in countable FTE; when calculating IME certain non-patient care activities (e.g. didactic conferences but not research) that occurs in the hospital will be countable.
• Closing or acquire hospitals - establishes rules for the redistribution of resident cap positions in this priority order: 1) hospitals located in the same or contiguous statistical area, 2) hospitals in the same State, 3) hospitals in the same region and 4) the priorities set in the redistribution of unused slots.

Amendments to Chairman’s Mark (9-19-09)

• Bingaman #D-2 - Ensures 50% of the GME slot redistribution is prioritized for rural and underserved communities.
• Bingaman #D-8 - Establishes 1) a grant program to provide Teaching Health Centers funding to establish primary care residency programs and 2) a program to provide direct and idirect GME payments for Teaching Health Centers to run primary care residency programs, funded at $250 million for FY11 to FY15.
• Stabenow-Snowe #D-18 - Allows residency training programs receiving initial accreditation by the ACGME or a new program number by the AOA from Jan. 1, 1995 to Dec. 31, 2006 to be treated as new programs with an adjustment to the hospital’s resident limit.
• Cantwell #D-2 - Establishes a loan program for hospitals starting new residency training programs in the following specialties: family medicine, internal medicine, emergency medicine, Ob-Gyn, general surgery, preventative medicine, pediatrics and behavioral and mental health.
• Nelson-Schumer-Cantwell-Kerry #D-6 - Increases the current cap in Medicare GME funded slots by 10,000.  1/3 of new positions would be distributed to hospital training more residents than their resident limit.  2/3 will be distributed on the following criteria: 1) likelihood of filling ths positions within 3 years, 2) primary care and general surgery positions, 3) training in community health centers or community-based settings, 4) states with more medical students than residency positions and with smaller resident to medical student ratios, 5) states with low resident to population ratios and 6) limit 50 FTE residency positions.  Also the IME will be paid at the full IME adjustment.
• Nelson #D-7 - Adds an additional number of new slots equivalent to $250 million in federal spending.  Slots will be available to hospitals in the ten states with the lowest resident to population ratio.  IME will be paid at full IME adjustment.

Chairman’s Mark V2

• Accepts Bingaman #D-2, adding reserved slots meet the additional criteria of being in a state among the top 10 in terms of the ratio of the population living in a HPSA.
• Accepts Bingaman #D-8, funded at $230 million for FY11 to FY 15 for the direct and indirect GME payments.
• Accepts Nelson #D-6 with modification - “allocates an additional number of new residency training slots for redistribution by adjusting the percent of unused slots that would be included in the pool for redistribution to 65%.  Slots allocated under this amendment will be available to hospitals located in the ten states with the lowest resident-to-population ratios.” IME will be reimbursed at the full IME adjustment factor.

So Magic 8 Ball - What’s the future for GME?

Answer: Ask again later… Senate Finance mark up is ongoing.

Yesterday, the New York Times’ Health section featured an article on a summer program at the University of Washington that exposes medical students to the real life experience of being a physician.  The program educates students on the practice of medicine as well as critical facets of the health care system that will affect them as practitioners. Please click the following link to read this excellent piece, and be sure to watch the accompanying video which is embedded in the article.

Summer of Work Exposes Medical Students to System’s Ills
September 8, 2009 - Kevin Sack, The New York Times

A recent research brief examining Community Health Centers (CHCs) in Indiana indicates financial investment in CHCs will ultimately result in savings for health care systems – totaling $473 million for Indiana in 2007.  These savings come from the lower cost of health care in ambulatory settings and reduced spending on preventable emergency room visits and hospital admissions.

These savings offer a glimmer of hope in the current health care reform discussions and there is every indication that Congress plans to capitalize on this system by increasing funding to expand Community Health Centers.  The House Tri-Committee bill entitled America’s Affordable Health Choice Act increases CHC funding from the FY09 $2.19 billion authorization to $6.4 billion in FY19.

But these investments often ignore one critical issue – health centers are already struggling to recruit and retain the necessary primary care physicians to provide the health care services that increase access and lead to cost savings.  In fact, primary care is struggling across the practice spectrum.  Medical student interest in Family Medicine is at an all time low and more and more Internal Medicine residents are choosing to specialize rather than go into primary care.

Thankfully, Congress hasn’t been blind on this issue.  In the House Tri-Committee Bill, there are a number of pieces to strengthen primary care – including primary care bonus payments, expansion of primary care focused medical home demonstration projects, increased funding for primary care training programs, and the creation of a new Medicare Teaching Health Centers (THCs) project.  The THC model brings together components which will both strengthen the current CHC system and build the future primary care workforce.  

THCs would increase residency training in community-based ambulatory settings by directly funding health centers to run residency programs.  The current model of Federal support for residency training directs Medicare Graduate Medical Education (GME) payments to hospitals, who sponsor residency programs which are heavily weighted towards the needs and specialty-based culture of most hospitals.  Providing funds directly to health centers would promote the establishment and support of residency programs focused on the community-based primary care culture of most health centers.

Placing residency programs in health centers would immediately augment the current workforce as residents provide service.  Teaching increases buy in and retention for health center physicians and THC graduates are much more likely to continue practicing in health centers and in primary care.  THCs also have an added benefit when located in CHCs which provide care to the uninsured pre-Medicare population – without health care these individuals will ultimately cost Medicare much more than if their medical conditions were well treated prior to Medicare entry.

All in all, an investment in Teaching Health Centers will lead to a more robust Community Health Center system, cost savings for the entire health care system and a primary care workforce that will be needed to care for the growing and aging American population.

In the June 8 Roll Call, Atul Grover of the AAMC asks –

If you or someone you love were gravely ill, where would you turn?

He suggests the best answer is America’s teaching hospitals and without an expansion of government funded graduate medical education, these hospitals will fade away. I agree that teaching hospitals provide service above educating the nation’s future physicians.  Innovation, research, standby services and charity care are all products of the academic health center.  However, the majority of these services are specifically funded by the government – through NIH funds and disproportionate share payments to hospitals which serve large uninsured populations.

Currently the crumbs of the piece of the pie that is GME likely do contribute to the other missions of teaching hospitals.  MedPAC estimates Medicare inpatient costs increase only 2.2% for every 10% increase in resident to bed ratio (also known as indirect GME or IME).  Yet Medicare pays IME at 5.5%.  Opponents to adjusting the IME rate argue the extra payments fund the other missions of teaching hospitals.  Whether this is the case or not, as we look to shoring up these missions, why would we continue to do it through a convoluted system whose goals are not those that we seek to satisfy.  If the government plans to increase support for the missions of innovation, research, standby services and charity care then it should do it with funding specifically directed at those missions.

Today’s teaching hospitals overwhelmingly turn out specialist physicians who are contributing to the extremely costly and disjointed health care system described by Dr. Gawande in his New Yorker article.  Dumping more money into the same system will only exacerbate the problem.  And dumping more money into the system in the hopes that the crumbs that fall off will support the other missions of teaching hospitals is expensive and bad policy.

On May 5, Senator Nelson (D-FL) introduced the “Resident Physician Shortage Reduction Act of 2009” (S. 973). A companion bill, H.R. 2251, has been introduced in the House by Representative Crowley (D-NY). In addition, similar provisions to lift the cap on Medicare-sponsored residency positions have been incorporated into the “Preserving Patient Access to Primary Care Act of 2009,” introduced by Representative Schwartz (D-PA), and are anticipated to be included in a companion bill by Senator Cantwell (D-WA). At the core of these bills is a fifteen percent increase in the aggregate number of Medicare-sponsored FTE residents in approved medical training programs. This increase, estimated to be approximately 15, 000 new residency slots, will be accomplished by a combination of redistribution of unused “old cap” and the creation of additional “new cap” positions. At first glance, the espoused goal of these bills— to lift the much-maligned cap on Medicare-funded residency positions to support the training of more primary care physicians— appears to be a move in the right direction. Upon further inspection, however, these bills fail to include any meaningful provisions to ensure that new residency slots are dedicated to primary care specialties and, in fact, include specific distributional criteria which would risk disproportionately increasing Medicare funding for subspecialty training.

Under the Nelson/Schwartz distributional scheme, one-third of new residency positions must be allocated to hospitals currently operating at least ten positions “overcap.” To be eligible under this provision, hospitals must also demonstrate that a mere 25% of all residents are training in primary care or general surgery programs. Thus, one-third of the “new” positions are reserved to fund existing positions. Recent AAMC data suggest that these “overcap” positions are overwhelmingly subspecialty. (1) As a result, only 10,000 of the estimated 15,000 slots are likely to be available for allocation to new primary care programs.

Even the remaining two-thirds of new residency positions are not required to be allocated to primary care. Hospitals are explicitly permitted to compete for these slots to fund any “overcap” positions not addressed in the distribution of reserved slots. Although reliable data are not readily available, AAMC data suggest that nationwide approximately 7000-9000 positions are currently “overcap.” The Secretary is further instructed to “take into account the demonstrated likelihood of the hospital filling the positions within the first 3 cost reporting periods beginning on or after July 1, 2010…” How might a hospital best show that it can successfully fill a residency position? By showing that there is already a resident occupying it. This provision provides another opportunity to allow subspecialty “overcap” positions to be preferentially sponsored.

Remaining positions are then to be allocated according to four unweighted preference categories:

· hospitals submitting applications for new primary care or general surgery positions;

· hospitals emphasizing training in community health centers or other community-based clinical settings;

· hospitals in states with more medical students than residency positions; and

· hospitals in states with low resident-to-population ratios.

These criteria lack stringency with respect to both ensuring that new positions are primary care and addressing the current geographical maldistribution of residents/physicians. For example, by preferring states with more medical students than residency positions, winners are likely to include at least fifteen states such as Florida, Vermont, Louisiana and New Hampshire. States qualifying under the resident-to-population provision include Florida and Arizona. (2) Insofar as any hospital within these states qualify for preferential treatment, there is no guarantee that slots will be awarded to the most appropriate primary care programs or primary care programs at all. In addition, while slots are to be allocated to hospitals that “emphasize” community-based training, this allocation scheme fails to establish and develop a pathway for direct support of teaching health center programs.

The looming primary care workforce crisis demands legislative action. The proposed Nelson/Schwartz scheme, however, seems to be a Trojan Horse - decorated with much rhetoric about primary care but really a vehicle for what teaching hospitals have long wanted - more public subsidies to add residencies of their choosing. Moreover, any significant increase in primary care slots over the next five years would come at the expense of other countries — many of them poor — as the growth in number of U.S. medical school graduates will be unable to keep pace with the proposed increase in new residency positions. As a result, most of the truly new positions created would pull more IMGs to the U.S. These IMGs disproportionately emigrate from lower income countries with devastating consequences for their home countries’ health care systems. (3) With a projected price tag of more than $10 billion over ten years, several alternative reform strategies, some of which have been incorporated into the Schwartz bill, have been proposed to more effectively and responsibly promote primary care workforce development:

· Support Teaching Health Centers: Redistribute unused “old cap” slots to Teaching Health Centers programs to directly support the development of community health center-based residency programs

· Guarantee Primary Care Expansion: Distribute residency slots using more stringent primary care preference criteria such as program primary care “track record”

· Establish National Health Care Workforce Commission: Develop national health professions workforce goals, recommendations and benchmarks

· Incentivize Primary Care: Expand scholarship, loan repayment and loan deferment opportunities for students and medical graduates

· Promote Responsible GME Growth: Ensure any increase in Medicare-sponsored GME cap does not exceed projected growth in the number of U.S. medical graduates while simultaneously moving toward self-sufficiency

Elizabeth Wiley, JD, MPH
Intern, Medical Education Futures Study
MSI. George Washington University School of Medicine

References:
1. Salsberg E, Rockey PH, Rivers KL, et al: US residency training before and after the 1997 balanced budget act. JAMA 300:1174-1180, 2008
2. U.S Census Bureau/ AMA Masterfile (2007)
3. Mullan F: The Metrics of Physician Brain Drain. N Engl J Med. 353(17):1810-8, 2005