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

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.

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.

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

The Medicare Payment Advisory Committee’s (MedPAC) March 2009 Report to Congress repeats its previous recommendation to Congress to:

1. Establish a budget-neutral primary care adjustment to the physician fee schedule
2. Direct the Secretary to adjust the calculation for the relative value units for expensive imaging machines in order to redistribute payments to other physician services.

Both are attempts to address Medicare physician fee schedule distortions which promote specialty care at the expense of primary care.

Since 1992, Medicare has relied on the Resource-Based Relative Value Scale (RBRVS) to determine the physician fee schedule.  Every physician service is assigned a relative value which is then multiplied by a conversion factor to determine the amount of payment.  The Relative Value Update Committee (RUC) advises the Centers for Medicare and Medicaid Services (CMS) on the work component of the total relative value of each new service and also assists with revaluing the work component of existing services. CMS itself is responsible for making decisions that determine the practice expense component of the total value of each of the 7000 services that CMS reimburses.

The RUC is sponsored by the American Medical Association and largely made up of members assigned by specialty societies.  Annually, CMS accepts more than 90% of RUC’s recommendations as part of a public rule-making process.  Fee schedule distortions which have emerged then are based on a combination of mis-estimates of work provided by the RUC and flawed assumptions about practice expenses that CMS has made. One might ask the question after 17 years of the Medicare Fee Schedule based on RBRVS why CMS still relies on estimates of components of the relative value units rather than empirical measurement. These empirical measurements would be available not only from other governmental units, such as the VA system, but also from health plans and providers. For example, why should Medicare pay on the basis of self-interested specialty estimates of the time it takes to perform a surgical procedure rather than actual “skin-to-skin” times and associated pre- and post-operative times available from actual OR logs.

Private insurers increasingly rely on Medicare’s RBRVS values in setting their own fee schedules. They have a direct stake in wanting the relative prices in the Medicare fee schedule to accurately reflect the real world – and, indeed, commonly complain that the Medicare Fee Schedule seems tilted in favor of technical and procedural services, while undervaluing primary care and evaluation and management services.  Yet, the private payers have been quiet about these perceived distortions, even as they rely on the Medicare relativities in their own negotiations with physicians.

MedPAC recently has taken up the issue of fee schedule distortions and there are signs that Congress is beginning to understand the problem.  The fact is that the Medicare Physician Fee Schedule is subject to notice and comment rule making, according to the Administrative Procedures Act, which guarantees that the public at large can have input into the rule making. As obvious stakeholders, purchasers’ and commercial insurers’ general and technical views would have to be given important consideration by CMS when reviewing RUC recommendations on work values and in its own estimates of practice expenses. The situation is not that of a single payer, imposing its bureaucratic will on the country — that then private purchasers and plans are stuck with.

The RUC is powerful but that is partly because other stakeholders have allowed it to be,   Thus far, the purchaser and plan community have appeared to opt out of the rule-making process, allowing the fee schedule to become overly responsive to specialist and corporate vendor interests.  CMS can’t easily reject RUC recommendations if no one else in the public — especially other affected stakeholders — don’t provide comments that reflect different perspectives and analyses from what the RUC process produces.

Bob Berenson, MD, Senior Fellow, The Urban Institute

The total number of PGY-1 residency positions offered and filled increased again this year, with 400 (1.9%) more PGY-1 positions filled.  However, despite a promising increase in family medicine position filled last year, the number of positions offered and filled is down again this year - 100 fewer positions were offered and there were 75 fewer positions filled (Figure).

Figure. Results of the NRMP, 1997-2009, for Family Medicine Positions Offered and Filled (Source: AAFP)

The number of internal medicine and pediatric positions offered and filled rose incrementally, but increases in these PGY-1 positions will not necessarily equate to more primary care as more and more of these residents are choosing to further specialize after their initial “primary care” residencies.

Congress is increasingly recognizing the physician workforce and medical student specialty choices as critical components to developing a health care system in the U.S. that is equitable, accessible and cost-effective.  But the 2009 Match is another step in the wrong direction and hopefully it sends a message.  The time to act is now.  

While much of the primary care stimulus funding was cut out in the Senate version of the Stimulus package, it was restored in a modified form in conference and signed into law by President Obama on February 17.  The final law gives a significant boost to community health centers - $500 million for services provided at CHCs and $1.5 billion for construction, renovation, equipment, and health information technology systems - and to the National Health Service Corps - $300 million for recruitment and field activities.  Primary care training funding received a modest boost of $200 million for Title VII and Title VIII of the Public Health Service Act and grants to training programs for equipment.

While increased support for CHCs and the NHSC are critical steps towards increasing care and access to underserved / uninsured communities, the relative levels of funding for these programs in comparison to the funding levels of the primary care training programs indicates a denial of what is and will be a core problem in providing health care to these communities and the nation.  Ultimately the question is - who will provide the health care that is funded through these programs?

CHCs and the NHSC rely heavily on primary care physicians to staff health centers and provide care in underserved areas.  But primary care is in crisis.  Medical students are entering primary care fields at all time low rates.  Yet the National Association of Community Health Centers (NACHC) report health centers currently need over 1,843 primary care providers and if they are to increase their reach, they will need over 15,000 additional primary care providers by 2015.

Solving the primary care problem in the U.S. will require changes in the physician payment system to reduce the income gap between primary care and specialist physicians and changes in the physician practice to maximize evidence based, quality care.  However, changes also need to happen in the primary care pipeline to ensure future medical students will choose to enter primary care fields and be ready to practice in the changing health system.  Many factors have been shown to promote primary care field choices - such as recruitment of students who intend to practice primary care, positive primary care experiences during medical school and strong primary care faculty - all of which are currently supported by Title VII grants.

Change needs to happen across the spectrum of the physician workforce - from practice and payment to recruitment and education.  It’s time to prioritize this issue and recognize the quick fix of funding CHCs and NHSC, without building the primary care workforce, will only lead to a future collapse of the system… to bright shiny health centers without the people to provide the health care within.

The current House Stimulus Package specifies $600 million dollars for strengthening primary care.  The funds are specifically targeted for:

• Training primary care nurses, physicians, and dentists under Title VII and VIII of the Public Health Service Act.
• The provision of health care personnel under the National Health Service Corps.
• The patient navigator program under Title III of the PHS Act.  

The Senate version maintains the $600 million for primary care training without the specificity of where the funds will be directed.

What would $600 million do for primary care?  

Based on FY08 appropriation levels for each of the specified House programs, distributing the stimulus funds based on the current distribution of appropriations and assuming a 2 year distribution of stimulus funding, the package would nearly DOUBLE each programs annual funding if baseline appropriations are maintained at the FY08 funding level.

The stimulus is a start and an opportunity to build these into the robust programs they need to be in order to truly address the problems of primary care, underserved areas, and health care disparities that are persistent and growing problems in the US health care system.

It almost makes too much sense. Students with more debt should choose higher paying specialties than students with less debt. Therefore, we should reduce the debt load of students to increase the likelihood that they enter primary care fields.

Although this argument is sound, it is not valid because a number of studies have demonstrated that debt level has little, if any, influence on students’ residency and career choices (1). If anything, those with MORE debt may choose primary care residencies more often than those with less debt (2).

While I am not advocating the doubling of tuition and fees of medical school attendance, I do want to ensure that we have enough primary care providers to meet the needs of patients in our current and any reformed healthcare system. Increasing their number will make health care reform more effective and more efficient. The question asked, then, is how set up systems that reproducibly increase the number of medical students choosing careers in primary care.

Reframing the aforementioned findings can help us propose such systems. One way to look at the findings is that is to realize that students choose to enter a primary care field (pediatrics) even at high debt levels. Our task is to find people who are intrinsically interested in pursuing such career paths.

A study published over a decade ago observed that students from rural regions and those who are underrepresented minorities are more likely to pursue primary care and work in environments with relatively less resources, respectively (3). Without spending any money, admissions committees at schools whose mission it is to educate the primary care providers of tomorrow could redouble their efforts to identify such students.

Once again, the challenge appears to be deceptively simple. If our goal is to have increasing numbers of medical students pursuing primary care then we should recruit and train those who want to pursue primary care. Combining these recommendations with ongoing empirically-derived efforts will help us to provide even better care for our patients.

David E. Myles, MS III

Yale University School of Medicine

1. Grover A. When Money Doesn’t Change Everything. Annals of Internal Medicine. 2008; 149 (6): 429-430

2. Jolly P. Medical School Tuition and Young Physician Indebtedness. AAMC. 2004: 1-25

3. Senf JH, et al. A Systematic Analysis of How Medical School Characteristics Relate to Graduates’ Choices of Primary Care Specialties. Academic Medicine. 1997; 72 (6) 524-533.