Advocates for physician-training programs have been nervously awaiting the report of the deficit-busting “supercommittee” as the bipartisan Congressional panel assesses proposals that could slash Medicare support for the training of medical residents by up to 60 percent.
On Monday, President Obama provided little reassurance that he would protect those programs when he unveiled his own plan to reduce the federal deficit by more than $3-trillion.
While less drastic than some of the cuts the Congressional group is considering to graduate medical education, the president’s plan would reduce Medicare’s “indirect medical education” appropriations to teaching hospitals by $9-billion, or 10 percent, over 10 years, according to the Association of American Medical Colleges. Those payments compensate teaching hospitals for the higher costs they incur for training health-care workers and providing complex specialty care.
Darrell G. Kirch, president of the medical-colleges’ group, said in a statement released on Monday that, under Mr. Obama’s proposal, up to 10,000 fewer physicians would be trained each year at a time when the organization is predicting a shortage of 90,000 doctors over the next decade.
“The long-term cost to the nation’s health will far outweigh the near-term savings offered by President Obama’s deficit-reduction plan,” Dr. Kirch said.
“By forcing drastic cuts to Medicare and Medicaid, this proposal will hurt beneficiaries, exacerbate the already critical shortage of doctors in this country, and cost tens of thousands of jobs that America can’t afford to lose.”
Medical residencies are the specialized training periods of three to eight years that medical-school graduates must complete before they can practice independently.
While medical-school enrollments have been rising, supervised training opportunities for their graduates have been capped since 1997, when Congress limited the number of residency slots Medicare would pay for to just over 100,000. The freeze was imposed at a time when health-care experts were predicting a glut of doctors; now they’re fearing the opposite.
In recent years, medical schools have expanded their class sizes and new schools have opened, but if training slots are cut, the physician supply won’t budge.
“Within the next six years, we are going to have more students enrolling in medical school than the number of residency positions available,” said Atul Grover, chief advocacy officer for the medical-colleges’ association. As a result, “people graduating with $200,000 in debt will have no way to complete their training and go out and practice medicine.”
Among those who could be hardest hit are the approximately 2,500 U.S. citizens who study medicine abroad each year, Dr. Grover says. Many attend schools in the Caribbean, hoping to return to train and practice in the United States.
Most residency programs fill their slots with U.S.-trained graduates before accepting those educated overseas.
The medical-colleges’ statement says the president’s proposed cuts would reduce access to care “at a time when another 32 million Americans will be entering the system as a benefit of the president’s own health-care legislation.” He was referring to the additional number of people expected to be covered by health insurance when mandatory coverage begins.
Double Whammy on States
The president’s proposal comes as the 12-member, bipartisan supercommittee, formally known as the Joint Select Committee on Deficit Reduction, is meeting to come up with ways to cut the federal deficit by at least $1.5 trillion over 10 years.
If the committee fails to come up with a deficit-reduction plan by Thanksgiving, up to $1.2 trillion in across-the-board cuts are to be triggered, with deep gouges expected in Medicare and Medicaid, both of which support residency training.
Those cuts would come on top of deep reductions many states have already made to their support for physician-training programs.
The situation in Texas offers an illustration of the impact that double whammy could have on states.
Texas lawmakers cut appropriations for graduate medical education by 23 percent statewide for the fiscal 2012-13 cycle.
“Texas has invested heavily in undergraduate medical education to meet the needs of our state, but in a schizophrenic policy decision, we’re cutting back on training positions for those graduates,” said José Manuel de la Rosa, founding dean of the Texas Tech University Health Sciences Center’s Paul L. Foster School of Medicine, in El Paso. The school enrolled its first class, of 40 students, in 2009. This year’s entering class has 80 students, but further expansion plans are now on hold.
The dean said that, starting with the class that will graduate in 2017, Texas will have more medical-school graduates than residency slots, meaning “that we’ll become a net exporter of medical students.” Proposed federal cuts would exacerbate the challenges of keeping home-grown doctors in Texas, he says.
Sergio A. Alvarado, a family and community-medicine resident at Texas Tech’s teaching hospital in El Paso, agrees.
“We need to be opening up more residency slots, not going backwards,” he said.
Baylor College of Medicine, which eliminated a family-practice residency program because of budget problems two years ago, lost 63 percent of its state support for the remaining program this year when legislators cuts its budget from $260,000 to $95,000.
“We’ve been able to keep all 10 residency slots by cobbling dollars together from other sources, but I’m concerned that over the long haul, we could end up having to reduce positions,” said Stephen J. Spann, senior vice president and dean of clinical affairs at the medical school, in Houston.
Texas lawmakers also slashed a loan-repayment program that gives breaks to residents who train in shortage areas by 78 percent, from $25.4-million to $5.6-million.
“We spend more than $250,000 per medical student, and we ship nearly half out of state to do their residencies,” said Tom Banning, chief executive of the Texas Academy of Family Physicians.
“That’s not a great return on investment.”
Fears Over Shortages
The AAMC predicts that over the next decade, a third of the nation’s physicians will reach age 60, a time when many will retire. Shortages are expected to be particularly acute in primary care.
If government funds for physician training are cut, drug and medical-device makers might step in to help foot the bill, potentially skewing young doctors’ prescribing and treatment practices, according to the American Medical Student Association, which has lobbied to prevent such potential conflicts of interest.
Sonia Lazreg, who is working as a fellow for the association during a break in her medical studies at Mount Sinai School of Medicine, in New York, says that, faced with tighter limits on residency slots, teaching hospitals will favor specialties that generate more income for the hospital.
“The supplemental funding is essential to keep positions open in primary care and in safety-net hospitals that provide care for people who need it most and can afford it the least.”
John Brockman, a fourth-year medical student at Case Western Reserve University, hopes to be matched with a residency program in urology this spring.
“There’s a lot of uncertainty not only about what’s going to be available for me next year, but down the road, since this is a five-year program,” said Mr. Brockman, who estimates that he owes $250,000 in student loans. “Not knowing what lies ahead is very scary.”
