The Medical Education Futures Study Blog

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