Stephen C. Shannon, DO, MPH

Combating Threats to Graduate Medical Education

As Congress and the White House continue negotiations on the deficit and the fiscal year 2012 budget, the dollars provided through Medicare in support of graduate medication education (GME) are under fire. The American Association of Colleges of Osteopathic Medicine (AACOM) has responded with a letter to Congress, a letter to President Obama and Vice President Biden, a press statement, a news release, and urgent appeals to its member colleges, asking them to lend their own advocacy efforts to protecting GME, which have resulted in approximately 1,500 responses to members of Congress. Nevertheless, I believe we are closer than we have ever been to a significant and potentially devastating cut in federal Medicare GME funding.

There is not a single lawmaker on Capitol Hill who is unaware of this nation’s current and projected physician workforce shortages. Not only are we facing a significant physician retirement wave (around 25 percent of physicians are age 60 or older), but there will be increased demand for physician health care services due to the aging of the population, a chronic disease epidemic, and the addition of 40 million Americans to the health insurance rolls.

In response to these trends, several major national organizations have called for large increases in the number of physicians to be graduated in the coming years, and parallel increases in the number of residency slots to accommodate the last stage of their training. See, for example, the Council on Graduate Medical Education’s “Enhancing Flexibility in Graduate Medical Education.” And, during the last two years’ of health care reform dialogue, there was one theme on which policymakers from both sides of the aisle agreed: a solution must be found to ensure that our health system provides more accessible, more affordable care to more Americans. To meet these challenges, we need more physicians to be trained, not fewer.

So how do the current proposals to cut funding for the last stage of physician training comport with these goals? They don’t. The Medicare GME program currently receives approximately $9.5 billion annually, which is used to fund an already insufficient number of residency slots each year. And the number of funded slots has been effectively capped since 1997. If Medicare funding for GME is cut, residency programs will be severely challenged in their ability to continue educating their current numbers of residents, much less the additional physicians the nation needs and U.S. medical colleges are all working so hard to produce.

Over the past decade, osteopathic medical education has greatly expanded in response to calls for increased numbers of physician graduates. This spring, the nation’s colleges of osteopathic medicine (COMs) graduated nearly 4,200 students, compared with 3,631 graduates in 2010, and just 2,536 a decade ago. The continued growth of the number of osteopathic physicians entering the health care field is vital to mitigating the nation’s physician workforce shortage. But if GME funding is cut, new graduates may find themselves hard-pressed to find residency positions in which to complete their training.

Are there better ways to fund GME? Yes. A number of organizations have called for models such as all-payer GME support, in which the costs of GME are shared by all insurance coverers of our population. While perhaps rational, there has been little movement in this direction in recent years. What about using the current funding in innovative ways to produce more physicians? That idea holds promise as well, and if an honest and open dialogue could be held, then I am sure some solutions might emerge. However, the current Medicare GME-funded system provides little flexibility or room for innovation where funding is concerned.

While new models are explored, it is important that the current system not be “broken.” The nation’s GME system has taken years to develop, and a sudden reduction in funding that could result in cuts to positions would take years to repair—time not available given the nation’s physician workforce needs.

I believe policymakers must work to find innovative ways to preserve GME funding and increase GME capacity, thereby recognizing the vital role GME plays in ensuring an adequate physician workforce. The osteopathic medical community must work together to ensure that current funding streams are sustained.

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July / August 2011
Vol. 5, No. 7 / 8