RECOMMENDATION 5
CONTINUE TO PROMOTE A REDUCTION IN THE NUMBER OF PHYSICIANS IN TRAINING, PARTICULARLY
SPECIALISTS. If there is not a significant decline in first year residency positions by the 2000-01 academic year, additional incentives for downsizing should be implemented. While there are many encouraging signs, the decrease in residency positions has been slow and the number of specialists in training still significantly exceeds the COGME recommendations.
While some fine tuning of the COGME goals may be appropriate, the current level of production of specialists, as documented in this report, is significantly above the COGME targets. Nearly 14,000 physicians entering training in the 1997-98 academic year were expected to enter non-generalist specialties. This was 41 percent more than the
COGME goal of 9,879 (50 percent of 110 percent of the 1993 graduates.) If new entrants into allopathic and osteopathic
residency positions do not drop to 20,655 (115 per-cent of the 1993 U.S. medical graduates) by the 2000-01 academic year (compared to the actual 23,143 in 1997-98), then additional downsizing incentives should be implemented. This might include
reduced Medicare funding for non-generalist training.
RECOMMENDATION 6
PROVIDE ENHANCED TRANSITION SUPPORT FOR SAFETY NET HOSPITALS THAT REDUCE THE NUMBER
OF RESIDENTS IN TRAINING. This should include the authorization of the use of National Health Service
Corps to assist in the voluntary downsizing of residents in safety net hospitals.
Hospitals that depend the most on residents for service may be the least likely to voluntarily reduce residents. Redesigning services and replacing residents can be difficult and costly—especially for safety net hospitals in underserved areas. For ex-ample, several hospitals with high percentages of uninsured patients in New York State decided against entering the Medicare GME demonstration due to the certain reduction of Medicare GME revenues and the expected cost of replacement staff. The current support available through the Voluntary Resident Reduction Program authorized by the
Balanced Budget Act may be insufficient to assure the fiscal stability of safety net hospitals that reduce residents. Additional transition funding targeted to support access to care for the uninsured is needed and appropriate. Additional funding for the National Health Service Corps and authorization to place practitioners (generalists and specialists) at
safety net hospitals that reduce residents is also recommended.
RECOMMENDATION 7
RESTORE THE EXCHANGE VISITORS VISA PROGRAM TO ITS ORIGINAL INTENT. National policies and administrative procedures related to physicians with temporary visas should be revised consistent with the original purpose of these visas.
The Council previously recommended a 4-year phase out of the policy of granting waivers of the requirement that physicians with J-1 visas return to their country of origin after completion of their residency training. Ending waivers would help restore
the exchange visitor program to its original purpose of helping other countries benefit from advances in medical training in America. The Council also continues to recommend that the number of years that J-1 visa physicians are required to live in their originating country after training (but before returning to the U.S.) be increased from two years to five years and that the use of H-1B visa for physician residency training be eliminated. These changes would reduce the drain of physicians from other countries
and facilitate more rational physician workforce policies in the United States.
RECOMMENDATION 8
ESTABLISH A STABLE AND EQUITABLE SOURCE OF LONG TERM FINANCING FOR GME. Graduate
medical education is a public good that benefits the whole nation. All payers should share the costs of training. The Council, therefore, recommends the development of an all payer financing system that would spread the costs of preparing a
well-qualified physician workforce equitably across all payers.
Training the future physician workforce is a service that teaching hospitals provide to the benefit of the whole nation. However, the current marketplace orientation of the health care system is not likely to provide sufficient funding to support
a quality education for the nation’s future physician workforce. The responsibility for paying for the training should not be the sole responsibility of teaching hospitals nor of Medicare or Medicaid. It is appropriate, therefore, that the cost of training be
supported by as broad a base of payers as possible.
The expansion of the competitive marketplace, including managed care, may erode the financial health of teaching hospitals. Many payers appear to have reduced their payments for medical services and do not explicitly pay for GME. This erosion in GME payments is likely to increase as competition
increases in the health care industry. The BBA, by reducing the rate in the growth of payments to teaching
hospitals, may also contribute to reduced support for GME. Quality medical education and training is costly. If support for training is inadequate, it will be difficult to assure the continuing supply of high quality health professionals expected by both
policy makers and the public.
RECOMMENDATION 9
ASSURE ADEQUATE FUNDING FOR TRAINING IN AMBULATORY SETTINGS. Policies related to financing
GME in ambulatory sites should be reviewed closely. If necessary, additional policies and programs should be developed to support quality training in ambulatory settings.
While a number of recent developments are supportive of increased training in ambulatory settings, these may not be sufficient to encourage a significant shift in training to these settings. This should be monitored closely to determine if current policies are sufficient to support the level of training in non-hospital settings necessary to prepare physicians for a health care system that emphasizes out of hospital care. The Federal government should provide technical assistance and support the development of models for effective training in ambulatory settings. Further revisions in financing policies may be necessary.
In 1999, the Council plans to undertake a review of current policies related to GME financing, including ambulatory care settings, and issue a report on the adequacy of current policies.
CONCLUDING COMMENTS
On a number of issues, such as further reducing the number of residents in training and increasing support for training in ambulatory settings, the Council has recommended modest steps. While the nation’s physician workforce goals have not yet been met, as this report documents, there has been clear progress. Recent developments provide support for
many of the COGME goals. The Council believes that the strategy recommended in this report—to promote a more effective marketplace, to develop a more integrated planning process, to provide financial incentives for priority goals, to work with States, and to advocate for more stable long term financing of GME—is an effective strategy. Given the
progress being made, recent developments and the potential impact of the above recommendations, the Council does not recommend major new Federal authority for determining the physician workforce or major new governmental expenditures. The Council is hopeful that the recommendations above will be sufficient to achieve the nation’s health workforce goals.
While the Council believes that the recommendations will help bring the future supply of physicians into balance with the nation’s requirements, these recommendations are not likely to address other high priority goals of the Council, such as
increasing the diversity of the physician work-force and the maldistribution of physicians. These goals continue to be a high priority of the Council and will require other actions to adequately address.
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