Preparing for Impending Physician Workforce Challenges: Trouble Ahead for Graduate Medical Education? Russell G. Robertson, MD Dean, Chicago Medical School 1
National Resident Matching Program Data Residency Match 2013 Results Show 99.4 Percent of Positions Filled the highest in the history of the NRMP 29,171 available residency positions had been filled at U. S. teaching hospitals 1,041 positions were unfilled, and 939 were placed in the Match Week Supplemental Offer and Acceptance Program SM (SOAPSM)-- the process used by NRMP for unfilled residency positions. During Match Week SOAP, U.S. allopathic senior students and prior-year allopathic medical school graduates accepted 662 positions, and osteopathic students and graduates accepted 90 positions. 2
NRMP Data The other 126 positions were accepted by students and graduates of international medical schools. More than 13,000 applicants were eligible to participate in SOAP because they were fully or partially unmatched. Of those, 2,076 were U.S. allopathic seniors, 980 of whom were completely unmatched By the end of Match Week, 452 more U.S. seniors had obtained positions, leaving 528 with no position. (last years total with no positions was 256) Almost 1,000 more U.S. seniors were competing for positions in 2013 than in 2012, 3
AAMC Recommendations for an increase in Undergraduate Allopathic Positions (45,266) applied to attend medical school in 2012, an increase of 3.1 percent First-time applicants, considered to be a barometer of interest in medicine, set another record, increasing by 3.4 percent in 2012, for a total of 33,772 applicants. First-time enrollment at the nation s medical schools grew 1.5 percent to 19,517 students, an all-time high At the current pace of enrollment gains, medical schools are on track to increase total enrollment 30 percent by 2016. Dr. Darrell Kirch noted that the robust growth in medical school enrollment will not translate into a single new doctor to care for patients unless Congress lifts the 1997 limits on residency training positions. 4
AAMC Policy on New Allopathic Medical Schools 2006 AAMC Policy Statement increase enrollment by 30% 2006 Florida legislature approves 2 new medical schools - Florida International and Central Florida 5
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New Allopathic Medical Schools 2009 FIU, UCF, Tex Tech, Commonwealth* 2010 Virginia Tech Carilion 2011 Hofstra, Oakland, FAU 2012 Cooper, USC Greenville 2013 U AZ Phoenix, C Mich, Quinnipiac 201- W Mich, UCR* 201- UT Austin, UT Rio Grande 7
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AACOM Recommendations for New Undergraduate DO positions Again in the 2010-11 application cycle (for Fall 2011 enrollment), the number of applicants to osteopathic medical schools through the AACOMAS process reached a new high of 14,087. The 7 percent increase in applicants between 2009-10 and 2010-11 continues the unwavering applicant pool growth that began after 2002-03. Fall 2011, a record 20,663 students enrolled at osteopathic medical colleges. 9
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Assessing the Environment TED MED Conference 50 Great Challenges 2012 16 Allopathic Schools with preliminary or provisional accreditation 6 Allopathic Applicant Schools 1 Allopathic Candidate School 3 new Osteopathic Schools AAMC: Two attempts to add a net new 15,000 GME positions no progress COGME: Recommended net 3000 GME position no progress MedPAC: Reallocation of $1.5 billion in IME spending 12
From the AAMC Preserving graduate medical education (GME) is essential to ensuring timely access and quality health care services for Medicare beneficiaries The current physician shortage will exceed 130,000 doctors by 2025 (in all specialties). The Medicare population will grow by 36 percent over the next 10 years. One in three physicians is expected to retire in the next 10 years. 13
From the AAMC Proposed reductions unfairly impact America s teaching hospitals GME cuts disproportionately target teaching hospitals, which comprise only 6 percent of all (5,800) hospitals. This small group of hospitals provides unique, costly, and often poorly reimbursed health care that benefits all Americans, including 75 percent of all physician training (GME); 80 percent of all ACS-certified Level I trauma centers (adult and pediatric); 28 percent of all Medicaid inpatient care; and 40 percent of all inpatient charity care. 14
From the AAMC MedPAC no longer recommends cuts in teaching hospital support In June 2010, it recommended preserving the 5.5 percent indirect medical education (IME) adjustment to support the training of physicians that are able to lead a new, high-performing health system. 15
The Resident Physician Shortage Reduction Act of 2013 (S. 577) Introduced by Senators Bill Nelson (D-FL), Charles Schumer (D- NY), and Senate Majority Leader Harry Reid (D-NV). Increases, by 15,000, the number of Medicare direct graduate medical education (DGME) and indirect medical education (IME) slots. Requires National Health Care Workforce Commission to submit a report to Congress by January 1, 2016, identifying physician shortage specialties. Requires Government Accountability Office study on strategies for increasing health professional workforce diversity. 16
Teaching Health Centers The THCGME program is a $230 million, five-year initiative which began in 2011 to support an increased number of primary care residents and dentists trained in communitybased ambulatory patient care settings. Eligible entities include community-based ambulatory patient care settings that operate a primary care medical or dental (general or pediatric) residency program. $150,000 per resident allotment $93 million was to be funded to support the initial costs of starting a new program, but those dollars were never funded 17
Net New GME Positions Salsberg, Rockey JAMA article: 6.8% increase in GME positions 1) Virtually all interventional subspecialties 2) All hospital funded 3) Closure of primary care programs Teaching Health Centers: 1) Currently 63 slots at 11 THC s 2) Total of 143 FTE s expected July 1, 2012 3) Program expires in two years 4) Start up costs were never funded by HRSA Public Health and Prevention Fund Primary Care Residency Expansion: currently 336 slots and projected 844 slots 18
Redistribution of Residency Positions 1357 positions reallocated in April of 2011 19
Residency Positions vs Applicants 20
Mixed Messages There is no cohesive message coming from academia/organized medicine with regard to GME that resonates with the public at large CMSS IOM AAMC Sentors Kyl and Reed Those messages that are out there are physician centric and not population centric (save for pediatrics and nursing) Medical School Deans Missing opportunities to emphasize team based care and effectively partner with other clinicians 21
COGME Recommendations 1) Preservation of current GME funding 2) Add 3000 new GME positions to address rural and urban underserved communities and needs in primary care, surgery and psychiatry 3) An urgent meeting of the AAMC and AACOM to: Convene the appropriate accrediting agencies representing the full continuum of medical education from UGME through GME The American Board of Medical Specialties The American Osteopathic Association-Bureau of Osteopathic Specialists The Federation of State Medical Licensing Boards TO: Propose a comprehensive review and development of new approaches for medical education and training in the US 22
Strategies Under Consideration New approaches to increasing GME positions should be developed with immediacy in light of the need for additional physicians and in the context of the number of expanding medical schools. Hospitals sponsoring GME programs should be evaluated with regard to the benefits to the communities they serve in light of the residency programs they sponsor and the need for the physicians they train. An in depth analysis should be conducted with regard to the manner in which teaching hospitals manage their IME funds. A new search for funding partners for GME should be considered in alignment with the needs of the communities in which physicians are trained. 23
Strategies Under Consideration Novel forms of GME structures should be studied for the purposes of identifying high performing consortia and careful deployment of resources. In cooperation with the ACGME, use the M-4 year of medical school towards PGY-1 credit for selected residencies identified in critical need. Re-consider accreditation guidelines for fellowships, i.e. does a resident going into GI, Cardiology, etc really require three years of general internal medicine/general pediatrics training? 24
Strategies Under Consideration Re-establish Medicare/Medicaid funding priorities for residency programs based on the net costs of running the residencies as opposed to the dramatic regional variations driven by Medicare discharge statistics. Place a priority on the funding of core residency programs (GIM, Peds, Surgery, OB, FM). Use the income developed through procedural specialties to self-fund those specialties Recognize the need for medical educational continuity through new interactions between the Liaison Committee on Medical Education (LCME), the Accreditation Council on Graduate Medical Education (ACGME) and State Medical Licensing Boards. 25
Transforming Patient Care: Aligning Interprofessional Education with Clinical Practice Redesign Engage patients, families, and communities in the design, implementation, improvement, and evaluation of efforts to link interprofessional education and collaborative practice. Accelerate the design, implementation, and evaluation of innovative models linking interprofessional education and collaborative practice. Reform the education and life-long career development of health professionals to incorporate interprofessional learning and teambased care. Revise professional regulatory standards and practices to permit and promote innovation in interprofessional education and collaborative practice. Realign existing resources to establish and sustain the linkage between interprofessional education and collaborative practice. 26
Conclusions There is a remote possibility that net new GME positions will be funded The more likely scenario will be a displacement of IMG s There is the possibility that medical schools in the Caribbean will self fund GME positions based on the large cash positions they hold There is a greater need to recognize the strengths of interprofessionalism in health care 27