The Medical Education Futures Study Blog

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