Uncap GME funding to break a dangerous training bottleneck

Graduate medical education isn’t just a vital resource for new physicians coming out of medical school to complete their clinical training and become practicing doctors. It also serves an important role in ensuring that all patients have access to the care they need now — a responsibility that is on the verge of becoming much larger.

Relatively few U.S. hospitals can take on medical residents and fellows, and they shoulder the entire responsibility of training graduates and making them the best doctors they can be. But the part in the health system that teaching hospitals play by running residency programs goes much further than that.

The hospitals and their program participants provide a stunning amount of complex and acute care. If someone in a car crash receives Level I trauma care, the chances are excellent that such hands-on care was provided by a resident or fellow. The same goes for an ill child treated in a pediatric ICU or a high-acuity patient transferred from one facility to another. A fifth or more of all U.S. hospital care — including 40% of care given to patients who can’t pay their bills — is provided by residents and fellows at the 6% of hospitals that are able to teach them while they work.

That’s why it’s so important that federal funding for this vital educational and clinical resource be continued and strengthened. It costs more than $100,000 a year to train each resident, adding up to an annual price tag of about $27 billion. Medicare pays about $9.5 billion of that amount, requiring teaching hospitals to rely on state and local governments, other payers or their own revenues to make up the difference.

Making ends meet in graduate medical education only will become harder if payment policies don’t change. In 1997, Congress capped the number of GME spots that Medicare pays for, effectively freezing the growth of core residency programs at teaching hospitals and starting a worrisome trend in physician education for the next 1½ decades. The worsening bottleneck in the pipeline is leading to increasing competition among larger groups of qualified medical school graduates for the limited number of residency spaces.

And the demand for care only will rise in coming years. The coverage expansions of the Affordable Care Act will bring in tens of millions of newly insured patients starting in 2014 even as large numbers of physicians are approaching retirement. The population as a whole is aging, and increasing rates of serious chronic diseases are putting more strain on the medical professionals caring for them.

That’s why lawmakers need to preserve federal funding of GME and boost the investment so it will support at least a 15% increase in the number of available slots — in line with several bills introduced in the past Congress. The American Medical Association, one of the organizations supporting the boost, outlined a compelling case for the legislative move in testimony to an Institute of Medicine panel in December 2012.

Lawmakers have tried to stanch the wound by redistributing unused slots toward specialties and geographic areas facing particular shortages, but such zero-sum shifts can do only so much. A major and sustained new commitment is necessary.

The greater worry is that Congress will cut, rather than increase, federal GME funding. Slashing the investment might produce a mirage of short-term savings, but the long-term price would be disastrous to health care. Residency programs would be frozen, and some would be forced to close down altogether, even if it requires dismissing residents partway through their training. If the collateral damage from shortsighted budget savings kills programs that are particularly vulnerable — such as pediatric residencies that are dependent on annual congressional appropriations — the already dire physician shortage projections could balloon to epidemic proportions.

New and existing medical schools for now have done their part by boosting the number of students they accept. But that commitment will have little effect on physician shortages if there are too few places for future graduates to finish their training. In addition to lifting the Medicare cap, Congress must ensure adequate funding for other federal GME programs, consider higher education legislation that addresses student loan burdens, and make permanent and expand visa waiver programs that allow foreign medical school graduates to train in the U.S.

Dozens of states and physician specialty organizations already have documented serious doctor shortages that will not get better without a serious upgrade of the physician pipeline that sustains current residency programs and allows new ones to launch. Considering how many years it will take once the needed funding is in place to construct new programs, obtain needed accreditations and move through the first physician graduates, there is no time to waste.