Local hospitals could hold key to boost residencies

After more than 20 years as a practicing gastroenterologist, Richard Greenwald, MD, is helping turn his community hospital into a teaching institution.

This year Dr. Greenwald, now vice president of medical affairs at Boca Raton Community Hospital, helped develop a module covering gastroenterology, the liver and nutrition for medical students from the new University of Miami School of Medicine program at Florida Atlantic University in Boca Raton. The hospital's partnership with FAU and the University of Miami to teach medical students is the first step in a long-range plan to cultivate more physicians for southeast Florida. By 2010, some 100 to 125 medical residents are expected to be training there.

Boca Raton Community Hospital may be the first hospital in recent years to take advantage of a little-used opportunity to get Medicare funding for new residencies. Because the hospital has never sponsored a residency, it is eligible for Medicare graduate medical education dollars, money that has been capped for existing programs since 1996.

Given concerns that a physician shortage may develop by 2020, Boca Raton could become a model for those looking for ways to expand residencies and physician numbers, work-force experts say. Right now, opening residencies at hospitals that haven't previously had them is the only route to get new government funding.

Richard Reynolds, MD, senior vice president of medical advancement at Boca Raton Community Hospital, wouldn't be surprised if others followed his hospital's lead. "As we look ahead, with the growth and aging of the population, we're going to have a doctor shortage," he said. "Current schools are going to expand, and other [community] hospitals will become teaching hospitals."

Many consider such expansion good news. But if more community hospitals do begin training residents, some say the practice raises a broader policy issue of how to best spend graduate medical education dollars.

"Hospitals are feeling a need to increase residency size, and they aren't getting the Medicare funding to do it," said Karen Fisher, senior associate vice president of health care affairs at the Assn. of American Medical Colleges. "If community hospitals are interested in taking on GME, that's great. However, from a public policy perspective, wouldn't it make more sense to expand GME through quality existing programs as well as newly developed programs?"

When Boca Raton Community Hospital begins teaching residents, Dr. Reynolds anticipates a mix of full-time faculty recruited from the University of Miami and part-time faculty from among the practicing physicians at the Boca Raton hospital.

While other community hospitals may choose to add residencies without changing their physical or organizational structure, the Boca Raton hospital may be unique in that it is using the opportunity to become a full-fledged teaching hospital. It's spending $750 million to transform itself from a 394-bed facility to a 530-bed hospital with room to add residents, as well as medical and nursing students.

Timing is one of the many challenges ahead.

Once a new residency is opened, the hospital has three years to add others before Medicare sets the hospital's final residency count. It can take up to two years to get a residency accredited by the Accreditation Council for Graduate Medical Education, Dr. Reynolds said, and each program needs eight months to interview and hire residents. The hope is to have between four and seven programs up and running in that three-year window.

Dr. Reynolds is confident that although his hospital doesn't have a tradition of training medical students or residents, it has physicians capable of providing caliber supervision. "There are a significant number of physicians at our hospital who are qualified today to be faculty at any medical school in this country," he said.

It also has a broad patient base to draw from, officials said, and is home to a large cancer treatment center.

Planning for the future

Like other states, Florida is dealing with resident programs that have grown only incrementally since 1996. Although teaching hospitals can hire residents above the cap established in that year, they have to find money outside Medicare to pay for them, something many programs can't do.

Experts estimate that training a resident costs roughly $100,000 a year, and with tight budget constraints, most hospitals have little leeway to make this multiyear commitment. Despite the Medicare GME payment cap, pressure from population growth has prompted schools to find more money to inch residency numbers higher. There were roughly 103,000 residents being trained in academic year 2005-06, compared with 101,000 in 2004-05 and 98,000 in 1996-97. This means approximately 5,000 residents are training without government subsidies.

The AAMC has recommended that allopathic medical schools raise enrollment 15% by 2015 and is now considering whether to raise its recommendation to 30%. To ensure that enrolling more students translates into training more physicians, the AAMC also is urging Congress to lift the cap on GME spending.

The American Medical Association supports the idea that there are current physician shortages in some geographic regions and medical specialties. In general, the Association supports lifting the government's cap on Medicare GME funding.