Saturday, July 04, 2009

Solving the Doctor Shortage - Forever

by John S. Wilson

The United States faces a doctor shortage. And while the shortage didn't create the health care problems we have, it will certainly exacerbate them. Evidence is clear that not only has a plentiful supply of doctors been a driving influence for our health care innovations in the past but that without it the Obama administration will be unable to implement universal coverage or increase access to care - which is the linchpin of any substantive health reform, whether Republican or Democratic. But financing the education of doctors is almost as complicated as financing the system itself.

Any solution must be holistic and do the following three things:

(1) Increase the amount of medical residencies, (2) Increase enrollment in medical schools, and (3) Better manage the cost of medical school education.

Benefits of a Growing Supply
A growing supply of doctors makes prevention care more possible, and (coordinated with coverage) lessens emergency rooms visits and, most important, it also induces innovations in health care delivery. As far back as 1985, Jeffrey E. Harris, a professor of economics at M.I.T., noted in Health Affairs Journal that increasing the supply of doctors has led to:

1)trending the health care system toward increased cohesiveness between physicians and other medical providers.

4) incentivized doctors to relocate to small communities as to avoid the increased competition in bigger locales.

2) increased pressure for hospitals to compete with "nonhospital forms of care such as ambulatory surgical centers, walk-in emergency centers, and diagnostic centers."

3) amplified the number of medical faculty members and thus increased the level of scientific research being done.

What Has Disrupted Supply?
The Council on Graduate Medical Education (CGME), a panel created by Congress to assess the amount of physicians needed, has long stifled efforts to increase the supply of doctors. Miscalculations were made based on outdated information and a lack of consideration for the amount of increased health services baby boomers would consume.

The American Medical Association (AMA) didn't help by lobbying Congress for years on the issue, categorically stating "oversupply [of doctors] exists or is immediately expected." Lower supply meant doctors were more likely to be high demand thus keeping salaries high. The AMA was the proverbial fox watching the hen house (while they now represent less than 20% of practicing physicians, the ethos remains the same).

Another significant factor is the lack of medical residencies. All doctors, whether graduates of US or foreign medical schools, must complete a residency. Thus, an increase in residencies must correspond with any increase in medical school graduates. But the determinant to increase the amount of residencies is more political art than objective science.

The Government and Residencies
Medicare, a federally funded program, reimburses hospitals for the cost of residencies and accounts for 40% of total funding. The government typically spends "$11 billion annually on 100,000 medical residents, or roughly $110,000 per resident" according to the Accreditation Council for Graduate Medical Education. This level has been about the same for over a decade. Medicaid typically funds 10% and other federal agencies such as the Veterans Affairs Department (VA), the National Institutes of Health (NIH), The Agency for Health Care Research and Quality, and the Maternal and Child Health Bureau, among other government actors provide funding as well.

The lack of residencies is so acute that hospitals have begun to fund additional residencies by other means. Some have used monies from state coffers or even private donors. While any growth in residencies helps to mitigate the supply issue, the specialty of residency is a better indicator of if access to care will be increased. Health care economists such as Thomas Getzen, PhD, executive director of the International Health Economics Assn., say "It's fair to say that the lucrative professions will grow, while the needed but less lucrative fields won't thrive."

The amount of primary care residencies must be increased. Adequate preventive care is contingent upon the supply of primary care doctors. Consumers without access to primary care doctors are on average more sick, disproportionately poor, and costlier to the system overall. Increasing access is the cornerstone of any proposal (and the reason why an individual mandate will likely be part of any reform) that highlights prevention.

Increasing Residencies
So how do we pay for the increased residencies? Medicaid is already under siege in most states. Medicare has unfunded liabilities of 1.2 trillion due to the prescription drug bill alone, according to former Medicare chief Mark B. McClellan. And the VA is reeling from the exorbitant costs associated with treating wounded and disabled veterans of the Iraq war.

In 2001, then-Senator Hillary Clinton (D-N.Y.) along with Sens. Chuck Schumer (D-N.Y.) and Jack Reed (D-R.I.) proposed the "Medical Education Trust Fund Act of 2001". Modeled after previous legislation introduced by Daniel Patrick Moynihan (D-N.Y.), the bill sought to overhaul the ineffective financing of residencies and graduate medical education by distributing costs among all health care actors, both private and public. The bill assessed all health care premiums a 1.5 percent tax, and divided such funds (including the previous contribution Medicare is already making) into five trust accounts categorized to fund teaching and non-teaching hospitals, primarily Medicare funded and non-Medicare funded hospitals.

A competing bill sponsored by Representative Ben Cardin (D-Md.) assessed a 1 percent tax. "A new per resident formula use[d] the national average of resident salaries and fringe benefits, adjusted for inflation and wage indices", according to the legislation.

Neither of these bills has progressed through their respective corridors of Congress. In fact, Congress has reduced the proportion of Medicare funding as part of the Medicare Modernization Act of 2003. It is imperative that Congress revive and pass one of the aforementioned bills so residencies and graduate medical education is no longer a piecemeal effort reliant on the political winds of Congress.

Standardizing the process and resting acting authority with the nonpartisan panel created for this purpose, the CGME, lessens the influence of lobbyists and the watering down of recommendations. Like the AMA and others, the Council has made flawed assumptions in the past but is still the best authority to make recommendations to Congress.

Increasing Enrollment in and Lowering the Cost of Medical School
Over the past thirty years medical schools have been slow to increase enrollment. The Association of American Medical Colleges has called for an increase of 30% by 2015, which is estimated will produce 5,000 new M.D. students. Also, 3 new medical schools attained preliminary accreditation last year - Texas Tech, University of Central Florida, and Florida International University - and will matriculate students this fall.

In addition more undergraduate institutions are evaluating ways to shorten the length of study, and they must continue to do so. Currently 36 schools offer 6 year combined BS/MD programs. Doubling this number could increase enrollment substantially. To entice schools to participate the NIH, the agency tasked with doling out health-related research dollars to universities, could benchmark a percentage of those dollars to program participation and their amount of student enrollment.

The most efficacious way of managing the cost without the federal government subsidizing school loans - because it can't afford to - is to require lenders to offer loan deferrals to students completing their residency. While this wouldn't drive down the cost of loans, it would certainly make them more manageable.

The burden has been passed around for too long in respect to how many doctors we need and when we'll need them with nary a politician staking responsibility.

No longer should the funding of residencies be an issue; no longer should disparate care be doled out in rural communities and emergency rooms across this country due to market failure or inefficiencies; no longer should private industry stand more united than the United States; and no longer should the fox be the only one watching the hen house.

Bio - John is a senior at Virginia Commonwealth University pursuing a double major in sociology and women's studies. He blogs at


Anonymous said...

This is the first original post I've read in weeks. Thanks so much for the mini-worksop on this subject.

Sarah said...

At any rate, I liked some of the NIH cartoons on VADLO search engine!