Fiscal Fix Needed for Physician Training

The deans of medical schools who gathered recently at the Association of American Medical Colleges in Washington D.C. talked with some urgency about physician needs in their areas.

"One said, 'We can't hire enough orthopedic surgeons.' Another who lives across the country said, 'We can't hire enough gastroenterologists,''' said Christiane Mitchell, director of federal affairs for the AAMC, recalling the conversations for me.

"There's no single specialty shortage or single region that has the biggest shortage," she says. "If you look at the physician supply in Boston, there are plenty of physicians. If you go to western Massachusetts, where I used to live, there are no physicians," in a manner of speaking, she adds. "You have to go to Albany, NY or to Vermont for healthcare or back to Boston. It's hard to say what the big need is; it varies from region to region."

The potential impact of looming physician shortages on the patient population may seem like old news, but there's a new "physician training fiscal cliff" looming due to the country's budget woes.  Maybe we should call it "the frozen fiscal cliff."

Indeed, some physician training programs haven't had additional funds since 1997, Mitchell says, and AAMC is desperately pushing for a change.

If not, physician shortages may worsen in years ahead because trained physicians won't have residency options without the adequate funding, she explains. And as President Obama and Congress try to sort out deficit reduction plans, there is still the possibility that they may decide on further physician training cutbacks, according to Mitchell.

At this point, "we're probably going to see the first physicians graduate from medical school with no place to train," Mitchell says. "If you don't do your residency, you don't get your license."

The AAMC sees it this way: while medical schools are educating new doctors to help address anticipated shortages, those docs may not be able to complete their training and enter practice unless Congress removes "a 15-year-old cap" that has limited federal support through Medicare for residency positions at teaching hospitals.

That's the message Darrel G. Kirch, MD, president and CEO of the AAMC, wrote in a letter to Congress this week. The AAMC is a not-for profit association representing 141 accredited medical schools in the U.S. and 17 in Canada, 400 teaching hospitals and health systems, as well as 51 Department of Veterans Affairs medical centers and dozens of academic and scientific societies.

The Medicare Payment Advisory Commission has estimated that there would be $454 million cuts from major teaching hospitals, according to AAMC. "Cutting GME will worsen dramatically and potentially double the shortage of 90,000 physicians we already expect by the end of the decade," Kirch wrote.

According to the AAMC, the U.S. faces a shortage of 90,000 physicians by 2020, and that number is expected to grow to more than 130,000 by 2025.

Deficit proposals to reduce Medicare GME support would "threaten access to critical services unavailable elsewhere and reduce physician training at a time when patient needs are increasing," Kirch wrote.

For Mitchell, it's a big part of her job to keep tabs on physician shortages and what she terms "inactivity in Congress and the administration" related to funding of physician education, as well as the pending collision of physician shortages and the patient demand for care. In a little over a year, as many as 32 million Americans will enter the health care system with health insurance, as the U.S. experiences the physician shortage.

That shortfall in medical service providers is exacerbated by the fact that one in three physicians is 60 or older, the typical age of retirement for doctors, Mitchell says. "Just like the general population is aging, and the Baby Boomers aging into Medicare, we have the physician Baby Boomers are approaching their retirement," she says.

The problem of medical school education funding, or as Mitchell puts it—"the massive cuts in support for physician training"—isn't as widely debated as the other issues, but may certainly add to the physician shortage as the AAMC sees it.

"Congress must lift the freeze on Medicare-supported residency positions," the AAMC said in a report this year. "Because all physicians must complete three or more years of residency training after they receive an MD degree, Medicare must continue paying for its share of training costs by supporting at least a 15% increase in GME (Graduate Medical Education) positions, allowing teaching hospitals to prepare another 4,000 physicians a year to meet the needs of 2020 and beyond."

Over the last several years, medical schools committed to increasing their enrollment by 30%, and "they did that with very little government support," Mitchell says. Those enrollment goals should be reached by 2016. However, during that time, there has not been a proportionate increase in residency positions, which the students need to practice in the U.S. and get their license, Mitchell says. That's because government funding has been essentially "frozen" for the past 15 years; those funds were part of the balanced budget act of 1997.

"Not only are they not increasing (the funding), they are proposing significant cuts. It would seem only logical that Congress and the administration try to make sure Medicare beneficiaries have access to care," Mitchell adds.

"The logic of cutting funding at this point... there is no logic," she says. "It's a shortsighted view, not a long-term view. It takes three years at minimum to train a primary care physician, five to seven years for an orthopedic surgeon, and nine years to train a neurosurgeon."

For the last several years, the AAMC and other physician groups have lobbied intensely to seek financing changes. Recently, the AAMC has changed tactics, and has attempted to show they are training physicians for a changing world with "high performance healthcare systems." That includes instruction of physicians as part of "true patient care teams," Mitchell says.

That focus was part of bipartisan legislation that was introduced this year that would expand the number of residency training positions in Medicare by 15,000 over five years, with funding to back it. The legislation has not been adopted, and is not expected to be with a lame duck Congress.

"Everything came to a halt in the 112th Congress," Mitchell says. "We're hoping for a bigger policy discussion next year."

Indeed, they need a fiscal fix.