More medical students, fewer residency spots, and a burgeoning patient base—all are coming down the track. And while it would be nice to say that there’s light at the end of this tunnel, in fact, say our experts, it looks like there could be a train wreck instead.
Dr. Jeff Wiese, Associate Dean for graduate medical education at Tulane University, has watched residency funding dry up for several years now. He states, “While residency funding has always been somewhat of a challenge, in the last few years it has been increasingly difficult. The Association of American Medical Colleges has rightly called for an increase in medical school enrollment to meet the demand for physicians. The problem, however, is that there has been no corresponding increase in funding for residents.”
This is a huge disconnect…there is an increase in U.S. medical school graduates entering residency, but in the absence of more funded residency positions, there is not a corresponding increase in residency graduates entering practice.
“Virtually all residency funding in the U.S. comes from the Centers for Medicare and Medicaid Services (CMS). And while CMS has capped the number of residency spots, almost all teaching hospitals are above the cap, meaning that these hospitals have made the determination that it is less expensive to enroll residents than to bring on full time staff. This is probably untenable, however, given the Accreditation Council for Graduate Medical Education (ACGME) requirements regarding resident supervision.”
A budgetary plan along the lines of, ‘robbing Peter to pay Paul’ doesn’t sound, well, very sound. But indeed, says Dr. Wiese, this is what is happening in many residency programs. “With residency positions capped, it’s a zero-sum game. When more manpower is needed in one program, it necessitates reducing another program. Those involved with the program being curbed naturally protest. And with all programs under pressure to adhere to the new ACGME duty hour requirements, no program is interested in having its complement reduced.”
As for the residents, says Dr. Wiese, they are typically removed from the financing pinches. “Residency budgets are fixed, so residents usually don’t feel these pressures. If there is a substantial shortfall in the number of residents to do the work required, however, the situation is different because the existing residents have to work harder to pick up the slack—all the while still trying to stay within the 80-hour work week.”
In the past, those on the hunt for funding would pick up the phone and call their friends at XYZ manufacturer. That is only a bit of nostalgia these days, however. “We have not pursued industry funding as we want to avoid any suggestion of impropriety. There is funding available from the Health Resources and Services Administration, but the grants are very competitive and are, on their own, unlikely to meet the total need. And even then, these grants are usually five years in duration, making long-term sustainability of these positions untenable.”
Ed Edahl/Wikimedia CommonsWhile multiple entities are attempting to bring attention to the issue of residency funding, says Dr. Wiese, there is no coordinated symphony as of yet. “We can debate forever about the number of doctors needed, but everyone agrees that a shortfall is imminent. Increasing the number of medical students doesn’t do any good if you can’t get them through residency. The only thing that is going to rectify this situation is the formulation of a multispecialty collaborative effort that can approach political lobbies and CMS.”
Dr. McCollister Evarts, former CEO of the University of Rochester Medical Center, was formerly Chief of Orthopaedics at both the Cleveland Clinic and the University of Rochester Medical Center, and former CEO, Senior Vice President for Health Affairs and Dean at Penn State’s Hershey Medical Center. He states, “Because of the resident cap, any time a department grows in faculty or in activities there is not a parallel growth in the number of residents. The gap is often filled in either by funding transferred from hospitals or by funds from the departments themselves. In some instances the faculty members are supporting resident spots. Resident salaries and benefits for orthopedics are approximately $70, 000-$75, 000 per year—not to mention malpractice insurance.”
In the future will we hear newly minted M.D.s floating around the community…asking, for example, “Do you want fries with that?” Dr. Evarts: “There are 15 new medical schools coming online in the next few years—how will these potential residents be funded?”
A model that could work, says Dr. Evarts, is the one being undertaken by the OMeGA Medical Grants Association.
“OMeGA has created a mechanism whereby pooled industry funds can be transferred to various departments that are then distributed by an independent party. The contributors can direct the funds to a given subspecialty, but they cannot ‘earmark’ the funds for any certain program or resident. Many more such funding mechanisms will be needed in the coming years.”
Also concerned about the residency funding situation is Charlie Clayton, Vice President for Policy at the Alliance for Academic Internal Medicine (AAIM). He notes, “In the last ten years there has been at least a 20% reduction in the indirect medical education funds that Medicare pays to teaching hospitals. Also at issue is that state funding for graduate medical education—which is largely financed through Medicaid—has gone down. Faculty often contribute to residency funding, but such monies are typically only sufficient to cover the rudimentary costs involved.”
Let’s take a look at all of the costs involved in supporting a resident: salary and benefits, faculty time for teaching, the use of simulators, online evaluation systems, and administrative costs like recruiting. In many cases, external funding, mostly Medicare GME payments, will cover the costs related to resident salaries and benefits, but will not pay for any of the other costs.
“How the gap will be filled depends on the relationship between the hospital and the department/faculty and what they can negotiate.”
For Clayton and others, the elephant in the room, however, is, “What about the money being distributed at present?” “Several parties are advocating for increased accountability for the monies that are being distributed now. The Medicare Payment Advisory Commission has recommended to Congress that one-third of the earmarked funding be put into a pool and only released if recipients can prove that they are meeting certain requirements. The goal is to ensure that programs are graduating residents who are prepared to provide solid patient care. To meet this goal every specialty needs to examine how they are training doctors and how that training is aligned with the needs of patients.”
Clayton adds: “Although we at the AAIM tried to get Medicare to support more residency spots as part of the healthcare reform, this did not come to fruition. We are pleased, however, that the reform act did include a provision to form a healthcare workforce commission that will be advising Congress.”
With six patients in various exam rooms, a pile of paperwork, and staffing issues, the average doctor may not often consider the issue of residency funding. But, says Clayton, they will feel it soon enough. “It is important that all parties concerned take workforce shortages and funding accountability seriously. The situation has only worsened over the last 20 years; sometimes it seems that we are at a point where the community has ‘cried wolf’ too many times, i.e., changing positions on possible physician shortages to saying there will be an oversupply. I will say that there is one positive change…the VA is expanding its support for residency slots (principally in primary care, but also in orthopedics).”
Years ago those in the halls of power had to face the Redcoats. As resources dwindle and patients increase, going forward it just may be the Whitecoats—and their friends in advocacy—with whom the powerful must contend.
