The first baby boomers turned 65 in 2011, and AARP estimates 8,000 boomers will hit the magic age for Medicare every single day for the next 16 years. Then there are the more than 30 million Americans who will have insurance coverage beginning next year under provisions of the Affordable Care Act (ACA). States, too, are grappling with expanding Medicaid to increase access to vulnerable populations. But the question remains … just who will care for all of these people?
A shortage of health professionals exists in a number of disciplines. The nation’s 141 accredited medical schools have expanded capacity … but there is a bottleneck when it comes to internship, residency and fellowship sites. Funding for graduate medical education (GME) has been stagnant for years and is now in very real danger of being drastically cut. And on top of those issues, the way medicine is dispensed in this country is undergoing a radical shift that will require physicians to re-think the way they deliver care.
Against this backdrop, a number of professional societies and healthcare education associations are working … both collaboratively and individually … to come up with new ways to ensure the pipeline of healthcare professionals can meet the demands of an expanded and evolving healthcare system.
A Numbers Game
Christiane A. Mitchell, director of Federal Affairs for the Association of American Medical Colleges (AAMC) said her organization anticipates a shortage of more than 90,000 physicians by 2020. Through AAMC’s Center for Workforce Studies, that shortage is predicted to jump to 130,600 by 2025.
Although this workforce shortfall has become part of the national conversation recently, Mitchell noted it certainly isn’t a shock to those in the field. “We have identified and projected future shortages for several years now,” she said. “Since the mid-1990s, this has been a growing concern.” With the aging population and rise in chronic conditions, Mitchell added, “We see this demand is really split 50/50 between primary care and specialty care.”
Exacerbating the increased demand is a shrinking supply of physicians. “We see about one in three physicians entering retirement age in the next seven to eight years,” Mitchell said. “We don’t have that large number of young physicians coming in. We actually have been working on that pipeline issue.”
To increase the number of young physicians, medical schools across the country agreed to increase enrollment by 30 percent by the 2016/17 school year. Mitchell said while a handful of new medical schools have opened, the goal is being met mostly by expanding class sizes at existing schools. And, she added, the nation’s medical schools are right on target to hit their goal. “They’ve done this with very little … if any … federal funding,” she noted of the expansion.
But increasing the number of medical students creates another issue. “You can’t practice medicine in the United States without completing a U.S. residency program. The number of residency slots has been effectively frozen since 1997,” Mitchell said, adding the freeze was part of the Balanced Budget Act that capped the federal government’s contribution to residency training programs.
Currently, she continued, there are about 110,000 slots for all GME needs. That figure includes 10,000 slots funded by teaching hospitals without any federal support. Of the training slots available, about 26,000 are for first-year medical residents, Mitchell said. “People don’t realize how few positions there are.”
She continued, “By 2016/17 when we see that 30 percent expansion achieved, we might see, for the first time, there are not enough first-year residency positions for those graduates.”
From sequestration to debt reduction teams on both sides of the political aisle, Mitchell said the concern is that no one is calling for an increase in funds to support training … and all of the groups are looking at additional cuts. Deficit reduction proposals call for cuts to GME funding in the neighborhood of 10 percent on the low end all the way up to cutting current levels by nearly two-thirds in the Simpson-Bowles proposal.
“Right now our priority is making sure we preserve the level of support we have,” said Mitchell. She added that those discussions are being used to explain why it’s critical to avoid cuts and to strongly consider increases to funding. “We spend a whole lot of our time right now educating Congress and policymakers.”
Ultimately, she said, “We need what we have now … and for them to make a meaningful dent in the shortage, we need an additional 3,000-5,000 training positions a year over the next five years … that equals about a 15 percent increase in training positions.”
Changing Medical Education
Although funding for GME is critical, it’s only part of the solution to changing the course of medical education. Jeremy A. Lazarus, MD, president of the American Medical Association, said meeting the needs of patients in the evolving healthcare landscape requires new approaches to care delivery and is the impetus behind the organization’s $10 million “Accelerating Change in Medical Education” initiative at the undergraduate level.
Although some medical schools have implemented new ideas and approaches, Lazarus said the AMA felt there needed to be a push to get more schools involved. “What we’re looking for are bold and innovative programs that will help create the next generation of physicians who are more attuned to the emerging healthcare system.” He continued, “We want to make sure our physicians of tomorrow are team-based and integrate care.”
To grease the wheels of innovation, the AMA is offering significant financial support to fund 8-10 of the best proposals received from medical schools. The organization has dedicated $10 million to fund the winning proposals over the next five years. After a call for proposals went out earlier this year, the organization received 119 proposals from 115 medical schools … 82 percent of the 141 accredited medical schools in the country. When asked if he was surprised at the response, Lazarus said simply, “We were delighted.” He added that he believed the overwhelming response was a sign of the broad recognition of the need to change medical education.
From the 119 submitted ideas, less than three dozen will be selected to flesh out their proposals with the winners announced in June during the AMA’s semi-annual policymaking meeting in Chicago. For the eight or 10 schools selected to move forward, Lazarus said, “We’re creating a learning collaborative so they can share innovations they are doing with medical schools around the country.”
The need for transformative change in medical education to align physician training with the evolving practice environment is integral to the AMA’s plan of work. “It’s one of the three strategic priorities we’re going to be working on over the next five years,” Lazarus said. The other key areas are improving outcomes while reducing healthcare costs and enhancing professional satisfaction and practice sustainability.
Mitchell with the AAMC noted other movements also are underway to increase access to providers and look toward more integrated learning and practice models. “The National Health Service Corps helps med students pay for their loans in exchange for practicing in underserved areas. That has a strong focus on primary care,” she noted. Mitchell added, Title VII grants to ensure a greater diversity in the physician workforce are also helping expose under-represented minority students to medical education.
IPEC — the Interprofessional Education Collaborative — has set up a new medical school curriculum where all types of providers from physicians to nurses to pharmacists learn at the same time. “They become better aware of how some services might be best provided by another practitioner,” explained Mitchell. She added the idea is for everyone to practice to the top of their degrees in a manner to maximize efficiency, communication, skill sets and collaboration.
Similarly, other advanced-level degree holders, such as nurse practitioners, might be tapped to provide some services that have traditionally been provided by physicians in the face of shortages. Mitchell said lessons could be learned from Massachusetts, which addressed a physician shortage by using non-physician providers but did so in a way that worked for the doctors. “I think there’s a good lesson there,” she said.
Lazarus said with workforce shortages across a number of health professions, it will be important to look for new ways to care for patients. “What we’re advocating for are physician-led, team-based, integrated practices.”
Creativity, innovation … and additional funding … will be necessary to prepare the medical students of today for the healthcare tomorrow.