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

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