Warnings of doctor shortage go unheeded

Original Reporting | By Mike Alberti |

The health care reform bill does include some provisions that address problems with physician availability, including five years’ worth of funding for the Teaching Health Center Graduate Medical Education Program, which will train primary care residents in community health centers around the country. Salsberg acknowledged, though, that the funding authorized — about $230 million — was not substantial, and that the program was only funded for five years. The bill also contains a provision designed to redistribute existing residency slots more efficiently (reallocating those that have gone unfilled in the last three years), but does not add new residency slots.

The healthcare reform legislation also created the National Health Care Workforce Commission which is charged with analyzing both supply and distribution issues in the workforce and reporting its findings to Congress. The first of two mandated annual reports by the commission is likely to appear in the next few months.


Little action for now

While there are some rumblings of new attempts to fund more residency spots through Medicare — staffers in both the offices of Senator Bill Nelson and Representative Joseph Crowley, sponsors of previous residency expansion legislation, confirmed that new proposals were being drafted or assessed — no bill on residency funding has been introduced, and no assistance for the creation of new medical schools is even being discussed.

“It really comes down to the dollars,” he said. “It’s easy to turn a blind eye to something when it’s expensive.”

And moving a bill will be a tough sell. According to staff in the office of Ways and Means Committee member Jim McDermott (D-WA), for example, the Congressman has not seen conclusive evidence that justifies a significant increase in the total number of Medicare-funded residency slots.

In the Senate, even some Republicans who have acknowledged physician supply problems in the past may be hard to convince. Back in 2009, Senator Charles Grassley (R-IA), said, “[i]t is easy to see that increased health coverage is useless without a workforce to provide care.” In an email response to Remapping Debate last week, Jill Gerber, Grassley’s press secretary, reiterated that sentiment: “If the health reform law continues to be implemented as intended, demand for health care services will rise, which will create problems for access to care.” But Grassley is dissatisfied with the way residency slots are being reallocated (focusing on increases in states with physician-to-population ratios lower than that of Iowa), and, according to his spokesperson, does not believe that Congress should consider lifting the residency cap until allocation issues are resolved.

Even if a consensus were to develop in Congress around the need to train more physicians, the funding required would remain an obstacle, according to Michael M.E. Johns, the chancellor of Emory University and a longtime proponent of increasing the supply of physicians.

“It really comes down to the dollars,” he said. “It’s easy to turn a blind eye to something when it’s expensive.”

In December of last year, the report of the National Commission on Fiscal Responsibility and Reform, titled “The Moment of Truth” (more commonly known as the Bowles-Simpson report), actually advocated for cutting Medicare funding to graduate medical education by $60 billion by 2020.

Salsberg added that he has not seen a willingness on the part of the country to “open up the floodgates again,” and fund measures that would increase the supply of physicians.

According to some advocates, that “willingness” is likely to come only after the consequences of inaction become more tangibly apparent. And by that point, the window for addressing the shortage for the next decade may already have closed.

Johns said that he does not expect substantial action on the issue until Medicare patients stop being able to get appointments with their doctors.

Richard Cooper goes a step further.

“You won’t see anything done about this until people are out in the streets,” he said. “And by that point it will be too late.”

Primary care versus specialists

According to the AAMC, part of the reason that efforts to increase the number of medical residency positions in the U.S. have been stalemated is the disagreement over how those spots should be distributed across specialties.

Primary care advocates, such as the American Academy of Family Physicians, believe that all or most of any new residency slots created should be earmarked for primary care providers, pointing to trends which indicate a decrease in the number of residents who train as internists, pediatricians, and geriatricians. Their argument is based on the idea that increasing access to preventive care would both reduce costs and improve outcomes, because chronic illness would be better managed, and primary care physicians tend to prescribe fewer unnecessary tests and services.

George Sheldon disagreed, saying that while it is important to increase the number of primary care physicians, that increase should not be done at the expense of specialists. An exclusive focus on primary care physicians, he said, “assumes that doctors are interchangeable, but primary care doctors can’t deliver babies, they can’t perform surgery, and they can’t manage many chronic diseases on their own.”

Sheldon pointed out that advances in technology, while driving specialization and sub-specialization in the physician workforce, have also improved the services that can be offered to patients. He pointed specifically to advances in pediatric neurosurgery, like 3-D computer imaging, that reduce the need for invasive procedures. He added that there are only four hospitals in the country that train pediatric neurosurgeons.

Christiane Mitchell of the AAMC said that the dispute about the allocation of additional residencies made it easy for Congress “to back out of” increasing funding for residencies, and was a major reason that additional Medicare funding for new residencies was not included in the health care reform package.

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