Searching for Sustainable Solutions to the Physician Shortage
By CINDY SANDERS
Adequate GME Funding Continues to be a Concern
Complex problems rarely have simple solutions. Certainly that is the case with the looming physician shortage facing the United States. New research published last month by the Association of American Medical Colleges (AAMC) shows increasing shortages looming for both primary and specialty care.
The new data outlined in the 2018 update of "The Complexities of Physician Supply and Demand: Projections from 2016-2030" provides a forecast based on a number of supply and demand scenarios, including an aging population on the demand side and heavier reliance on other physician extenders on the supply side. Recognizing it is impossible to accurately predict exactly how market forces will play out over the coming years, each supply scenario is paired with a demand scenario to create a projected shortfall range.
Part of AAMC's commitment to annually updating physician workforce projections, the latest report increased the forecasted physician shortfall to between 42,600 and 121,300 by 2030. This is up from last year's report, which projected a physician shortfall of 40,800 to 104,900 by that same year.
The shifting demographics of the U.S. population continue to be a key driver of demand. "Our data shows by 2030, the U.S. population aged 65 and older will grow by 50 percent," said AAMC's Chief Public Policy Officer Karen Fisher. She added the supply side of the equation is impacted by several factors including the hours physicians are willing to work, the number of providers nearing retirement, and the quantity of young physicians completing training to fill in those gaps.
Allopathic and osteopathic medical schools have both seen increases in enrollment over the last several years as academic centers have pledged to help alleviate projected workforce shortages.
According to AAMC data, there were 21,338 new enrollees in allopathic medical schools for the 2017-2018 academic year, a 1.5 percent increase over the previous year. Total enrollment for 2017-18 was 89,904 students compared to 81,936 in the 2012-13 year, a nearly 10 percent increase over the last five years and closer to a 20 percent increase over enrollment a decade ago.
The American Association of Colleges of Osteopathic Medicine (AACOM) saw first-year matriculation jump with a nearly 7 percent increase in fall 2017 enrollment over the prior year. Preliminary figures from AACOM placed 2017 total enrollment at 28,981, an all-time high for the 34 accredited colleges of osteopathic medicine in the United States.
While growing medical school enrollment is a positive step, Fisher and colleagues point out increasing the number of students won't translate into more physicians and surgeons if there aren't adequate training slots for graduates.
"The Medicare program has been a key financer of graduate medical education," said Fisher, who added Medicare historically funded GME on a proportionate share of a resident's training. For example, if a resident trained at a facility where Medicare made up 30 percent of the patient population, then the federal program would pay 30 percent of the physician's GME cost.
However, continued Fisher, "In 1997, Medicare placed a cap on that support ... so for over 20 years, Medicare's support has been capped at the number of residents in 1996." For every resident above the hospital's cap, she said, the facility has had to absorb that extra cost. "It's like they are taking a cut every year by virtue of that cap," Fisher added.
For the most part, she continued, there have been slots available for graduates because hospitals have borne the additional training costs. In some cases, states have stepped in to help with additional funding, as well. However, Fisher said sustaining the current setup is an ongoing concern. "When clinical revenues get tight, we're very concerned about the ability of teaching hospitals to continue to train residents above the cap," she said. "It's important that we continue to receive stable, predictable financing to offset the significant costs associated with training new physicians."
AAMC, along with AACOM, strongly supports legislation that would moderate the chilling effect the current cap has on physician training. "We're asking for 3,000 residency positions each year for five years for a total of 15,000 residency positions," noted Fisher.
The bipartisan Resident Physician Shortage Reduction Act of 2017 (HR 2267, S 1301) was introduced last May but didn't make it out of committee. However, Fisher said there might be another chance to gain some traction if Congress takes up infrastructure this year. "I think the physician workforce is an important infrastructure need for the health of our country," she pointed out.
AAMC officials have repeatedly stressed the need for a multi-pronged approach to addressing the physician shortage. While enrollment and GME are huge components to the solution, there are other factors being addressed, as well.
"Overall, our modeling certainly looks at the role and growth of nurse practitioners, physician assistants and telehealth," she said of utilizing teams and technology to extend the delivery system.
AAMC also supports non-GME incentives and programs, including Conrad 30, the National Health Service Corps, loan forgiveness programs and Title VII/VIII, which are used to recruit a diverse workforce and encourage physicians to practice in shortage specialties and underserved communities.
Fisher said foreign-born physicians are another potential part of the solution and noted those trained outside of America must undergo a rigorous assessment before being allowed to practice in the United States. "They are an important source of physicians in this country," she said. "Many of them tend to practice in rural and underserved areas," she added of filling gaps in care. Additionally, AAMC has been a champion of increasing the physician workforce in a manner that embraces diversity and cultural competency to mirror the nation's changing demographics and to work towards eliminating health disparities.
Fisher noted the AAMC also has released several statements calling for healthcare workers with DACA status to be able to continue their education, training and research. Similarly, the organization has expressed concerns over executive actions on immigration and travel impacting researchers and clinicians. In an issue brief from March 17, 2018, the organization noted, "Because disease knows no geographic boundaries, it is essential that we continue to foster, rather than impede, scientific cooperation with clinicians and researchers of all nationalities as we strive to keep our country safe from all threats."
Fisher concluded, "We certainly support national security, but we believe this is an issue of national health security."