The United States faces a massive physician shortage that should reach serious proportions by 2025 as the aging population grows while health care reform increases the need for more doctors. But another reason for the coming shortage is the result of a government-imposed cap on the number of federally funded graduate medical education, or residency, positions and proposed federal budget cuts that will further decrease their availability.
President Obama’s 2015 budget calls for $402 billion in health-related cuts over 10 years, which includes almost $15 billion in Medicare Indirect Medical Education payments. Medicare is the primary supporter of residency programs, currently funding over 75 percent of physician residencies.
However, according to the Association of American Medical Colleges (AAMC), the number of students accepted into federally funded residency programs has been capped at 85,000 for the past 18 years.
“The number of funded physician residencies for each hospital in the United States was set in 1996, and there have been almost no changes since then,” says Stan Breaux, Executive Director for Medical Education at Baptist Health System (BHS). “We have seen the swapping of these positions through various programs, but any growth has occurred at the expense of other systems.”
Breaux says the Affordable Care Act (ACA) gives the Centers for Medicare and Medicaid Services the authority to take positions from residency programs at closed hospitals and redistribute them to other facilities. However, the legislation does not provide for the overall growth of these positions. “There is no easy way to increase the number of positions, other than BHS funding this growth in residency positions ourselves,” he says. “Currently, we are operating with more residents than the government is willing to fund, as are other residency programs in the state, but it’s hard to do that forever. Even if we could have funded extra positions 10 years ago, inflation would keep us from being able to fund them on an ongoing basis.”
Medical schools recognized the impending physician shortage years ago and began to take steps then to expand enrollment, which is on track to increase by 30 percent from 2003 to 2017. However, without the federal government lifting the cap to fund additional residency slots, the National Resident Matching Program predicts that the number of residency applicants graduating from American medical schools will soon exceed the number of available positions. The mismatch could prevent medical school graduates from completing their education and will reduce the number of new physicians available to avert the predicted 2025 shortage of up to 130,000 doctors with about 30 million new patients seeking expanded access.
“We are already seeing a small number of U.S. graduates who don’t get matched the first year, and it is extremely hard to get matched after that year,” Breaux says. “If we start graduating more U.S. citizens than there are residency positions, the competition will get worse. These physicians have invested eight years in college and medical school only to find that they are incapable of completing their training, getting a medical license, and a job.”
According to the New England Journal of Medicine, there are 117,604 residency-training posts accredited by the Accreditation Council for Graduate Medical Education. In the 2013 main residency match, 25,463 positions were filled with 17, 119 graduates of U.S. medical schools, 6,307 graduates of international medical schools, 2,019 graduates of colleges of osteopathic medicine, 14 graduates of Canadian schools, and four from other programs. “In a few years, just the U.S.-born graduates are predicted to exceed the number of residency positions in our country,” Breaux says.
Leaders at the AAMC have another concern about the proposed budget cuts in medical education – the fact that most of the reductions will be from programs that support teaching hospitals. In a 2011 report, the AAMC stated, “As a result of their unique capabilities and responsibilities, teaching hospitals’ costs are higher than those at other hospitals. For example, there are significant expenditures associated with the training offered at teaching hospitals for new physicians and other health care professionals. In addition, these hospitals provide the clinical environment in which this training can occur. Teaching hospitals are sites that treat the most complex patients, maintain standby capacity for a full range of emergency services (many unavailable elsewhere in the community), are the first adopters of cutting-edge technology, and provide specialized services such as trauma and burn care. They are sites for clinical research and many are safety net providers in their communities.”
AAMC President and CEO Darrell Kirch, MD says that additional cuts to teaching hospitals would make it difficult for them to carry out the above stated mission. He also mentioned the possibility of financially exhausting the ability of teaching hospitals to train additional resident positions. “These institutions already are supporting 10,000 residents per year above the federal residency training position cap, at a cost of more than $1 billion annually,” he says.
Breaux doesn’t know how this issue will be resolved, but at BHS, they are doing their best to manage. “Despite the nationwide crunch, we have been able to grow our positions a little bit, and other hospitals in Birmingham have also,” he says. “We hope Congress will take these issues seriously and address the physician shortage issues definitively for the sake of our patients and for the sake of the current medical students in the training pipeline.”
