If you are like most medical residents and fellows, you probably do not regularly reflect on the federal government’s role in your graduate medical education (GME). In deciding where to study and train, you may have considered factors like class size, availability of specialty services, and diversity of training environments – but you may not have been aware of the complex influence of the law, federal insurance programs, and payment rates on your medical education. Now, active federal legislation is reinvigorating the conversation regarding GME, the impending physician shortage, our rapidly aging population, and equitable access to health care for all Americans.
The Balanced Budget Act of 1997 enacted sweeping legislation to reduce federal spending, and it did so largely with adjustments to Medicare payments. Part of this was accomplished by imposing caps on the number of residents for which teaching hospitals were eligible to receive GME funding. Medicare is the largest single program that supports GME and primarily does so through Medicare Part A, which also pays for inpatient hospital services, skilled nursing facility, home health, and hospice care. At a basic level, Medicare funds GME through two avenues: direct GME (DGME) and indirect medical education (IME) payments.
DGME payments cover some of the direct costs of training residents and fellows: stipends, benefits, programming, education expenses, and overhead. IME payments are a bit more complex, so suffice it to say that these payments are intended to pay teaching hospitals’ increased patient costs linked to treating more complex patients. In fiscal year 2016, DGME funds paid to teaching hospitals totaled $3.79 billion, but an estimated total $18.5 billion in direct training costs were incurred. Some, but not all, states supplement funding support with Medicaid, so teaching hospitals are forced to find other avenues to offset these costs.1
The AAMC projects that by 2032, the United States will have a shortage of between 21,100 and 55,200 primary care physicians and between 24,800 and 65,800 surgeons and other specialists. Research from the American Association for Thoracic Surgery estimated that at current rates of growth and transition, by 2035, cardiothoracic surgeons will have to increase their workload by 121% to meet demands.2 At the same time, by 2032, the number of Americans above age 65, the age group with the largest per capita consumption of health care, will grow by nearly 50%.3 An estimated one-third of the current physician workforce is older than 55 years and is projected to retire within this time frame. Teaching hospitals are already supporting over 12,000 residency positions which are not funded by Medicare.4 In 2002, the Association of American Medical Colleges (AAMC) sought to mitigate the impacts of his physician shortage and aging of the population by calling for a 30% increase in medical school enrollment. Since then, with expanded class sizes and the establishment of 26 new medical schools, the AAMC met its goal and the number of medical school matriculants has grown by more than 31%.5 However, without the commensurate increase in postgraduate training positions, this growth in medical school matriculants alone cannot alleviate these crises. Finally, given that fully training a physician can take anywhere between 3 to 11 years, the time to act is now.
Earlier this year, bipartisan members of both the United States House of Representatives and Senate introduced a bill called the Resident Physician Shortage Reduction Act of 2019 (H.R. 1763/S. 348) which aims to increase the number of Medicare-funded residency positions by 15,000 above the current cap – 3,000 positions each fiscal year from 2021 through 2025. The bill includes provisions to prioritize hospitals that train residents in primary care and in general surgery and programs that emphasize partnerships with Veterans Affairs medical centers and rural and/or community-based settings. This is a major first step toward enabling the physician workforce to meet the demands of an already strained American health care system. Ultimately, without this boost in the physician pipeline, the vulnerable and under-resourced patients will suffer most.
There are other non-GME programs that also need our support to ensure a diverse, inclusive, and geographically representative workforce. These include the National Health Service Corps, the State Conrad 30 J-1 Visa Waiver program, and Title VII/VIII training programs, all of which you can learn more about through the AAMC website.
Last month, over 65 medical associations and specialty societies sent a joint letter to the members of the U.S. Congress strongly encouraging them to cosponsor the Resident Physician Shortage Reduction Act of 2019, and you can do the same! A quick email or phone call as a voting constituent can go a long way; you can start by finding your representatives here. If you are interested in learning more about advocacy in cardiovascular medicine, start by reading my co-Early Career Blogger Christa Trexler’s January blog here and the AHA’s advocacy resource website here.
- US Capitol by shashank singh from the Noun Project
- Book by Kiran from the Noun Project
- Money by Andreas Vögele from the Noun Project
- Doctor by Iconic from the Noun Project
Nosheen Reza is a fellow-in-training in advanced heart failure and transplant cardiology at the University of Pennsylvania in Philadelphia, Pennsylvania. Her interests include cardiovascular genetics and inherited cardiomyopathies, and she volunteers as a member of the AHA Fellow-in-Training National Steering Committee and the Council Operations Committee. You can follow her on Twitter at @noshreza.