FINDING 3: Recent developments may support more training in ambulatory settings; however, additional policy initiatives may be needed. Medical schools, residency review committees, States and foundations are promoting increased
training in ambulatory settings. The expansion of the settings and arrangements under which Medicare will recognize the costs of training outside of the hospital authorized by the Balanced Budget Act should also help. However, there are concerns that the changes authorized by the BBA do not adequately address the policy goal of optimal use of ambulatory training and few, if any, non-public payers provide enhanced reimbursement for physician training in these settings. It remains to be seen whether the recent pressures to shift training to ambulatory settings and the more supportive Medicare
payment policies will be sufficient to overcome numerous financial, logistical and other barriers impeding the expansion of quality ambulatory training opportunities.
FINDING 4: There is no system for health workforce planning and guidance. Although the nation has made some progress towards specific workforce goals, there has been very limited progress on other goals. Furthermore, there is no system in
place to monitor progress and provide long-term guidance to the health and education sectors. The lack of firm data and information on supply and demand by specialty by region also makes it difficult for medical educators and medical students to respond to the nation’s needs. Furthermore, while the Council provides important guidance to the medical
education community, the recent sharp rise in the number of new non-physician clinicians, whose scopes of practice overlap with physicians, demonstrates the need for a planning system that includes both physicians and non-physician clinicians.
There has been a significant increase over the past few years in the numbers of nurse practitioners, physician assistants, chiropractors, and other health professionals who provide extensive patient care services. The number of these non-physician
clinicians will continue to grow in the foreseeable future. This growth has major implications for physician workforce planning.
The Council finds that specialty selection by medical students and the number of positions offered by residency programs are at least somewhat responsive to supply and demand. The recent growth in interest in generalist specialties and drop in interest by graduates of U.S. medical schools in crowded specialties, such as anesthesiology, demonstrates their responsiveness to the market. When supply exceeds demand and graduates encounter difficulty finding a satisfactory position, some residency programs respond by downsizing positions.
FINDING 5: The dependence on hospital patient care payments to support the GME infrastructure in an increasingly competitive environment poses a threat to the nation’s physician training sites. The available data on the financial health of the nation’s academic health centers and other teaching hospitals do not indicate a general fiscal crisis at the present time. However, many of the recent developments raise serious concerns about their future fiscal viability. The competitive
marketplace and the drive for payers to contain costs are likely to put increasing fiscal pressure on most hospitals and ambulatory service sites as managed care plans and other payers seek to limit their expenses.
Health care is more costly in hospitals and ambulatory care sites that are engaged in residency education. In addition, teaching hospitals, particularly academic medical centers, provide many related public goods that can add even more to costs, including care for the uninsured, research, teaching of medical students and other health professionals
and the development and testing of medical innovations. The reliance on add-ons to patient care services
to support GME is unsound in a period of increasing competition and growing cost cutting efforts.
FINDING 6: Recent developments do not bode well for safety net providers that train physicians. Safety net providers face the same pressures as other teaching hospitals and ambulatory care sites, but they serve significant percentages of uninsured patients and have less leverage negotiating with managed care plans and other payers. Physicians in training
are important providers of care in these institutions. To the extent that GME reimbursement is reduced through the competitive marketplace without an increase in funding for care for the uninsured, services for the uninsured and the fiscal viability of safety net teaching hospitals will be endangered.
FINDING 7: Recent developments have the potential to significantly impact the supply and demand for physician services. There are several recent developments that have the potential to significantly impact on the supply and demand for physicians. They include: the changing marketplace; the increasing percent of physicians that are female; the 1997 Balanced Budget Act; changes in testing procedures for international medical school graduates wanting to enter training; changes in VA training policies; and the Medicare GME downsizing demonstration in New York. All of these need to be considered when developing recommendations for tomorrow’s physician workforce.
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