On March 15, tens of thousands of medical students will participate in the National Residency Match, hoping to matriculate into a Graduate Medical Education (GME) program -- within a system that is unable to meet our nation's healthcare needs. The U.S. has arrived at a healthcare provider cliff and we are not training enough doctors to fill the gap, as not every applicant will be able to match into residency. According to estimates from the Association of American Medical Colleges (AAMC), we will be short in just 10 years, a problem made worse by an exodus from the workforce of in 2021 alone.
This crisis is increasingly impacting rural communities, where hundreds of hospitals are , shifting patient volumes to the . Recent cuts to Medicare reimbursement rates may make this problem worse, pushing more rural hospitals and practices to insolvency. Meanwhile, providers are feeling the toll. Shortages have contributed to unprecedented levels of burnout, as some physicians pack more than , pushing patients who into shorter and shorter appointments just to keep up with demand.
How Did We Get Here?
The pipeline to becoming a licensed physician in the U.S. is primarily through residency training positions at teaching hospitals. Funding for these positions is , but the majority comes from Medicare. This arrangement was established by the , with the understanding that a sudden influx of elderly patients would require a sizable workforce of physicians. This mechanism, however, was , until we could devise a more sustainable solution.
The current Medicare funding structure for GME operates through two major streams. One of those streams, the Direct Graduate Medical Education fund, is calculated from a (PRA) based on an individual hospital's average cost of supporting a full-time resident in 1984. Though these amounts have periodically been adjusted for inflation, today's payments are still subject to the same 40-year-old financing scheme that for changes in healthcare costs.
In the late 20th century, federal committees, think tanks, and various advocacy groups predicted an impending surplus of physicians that would and lead to wage reductions. Consequently, these groups advocated for on the number of residency positions and on medical school growth. Congress responded by capping Medicare funded residency positions at a hospital's number of "full-time equivalent" (FTE) positions in 1996. These caps mostly remained in place for over 20 years, despite , the transition of into Medicare, and increasing , which have made old provider staffing numbers obsolete.
In the mid-2000's, when it became apparent that the country was actually headed toward a provider shortage, various interest groups, including the , changed course and advocated for increasing the physician supply. But the damage was already done: enrollment in medical schools 33% from 2002-2020, but a failure to concurrently adapt GME funding created a bottleneck. For several years now, despite our current physician shortage, thousands of medical school graduates into residency positions.
What's Being Done?
Congress approved the first significant statutory reform to GME funding since 1997 as part of the broader Consolidated Appropriations Act of 2021. The legislation added up to 1,000 new over a period of 5 years, starting in 2023. While it's a step in the right direction, an increase of 1,000 spots is a drop in the bucket.
More substantial reform has been proposed in the , which would add up to 14,000 new positions over 7 years, giving individual hospitals up to 75 new FTE spots. The AAMC estimates that combined, these legislative changes could add annually, once fully implemented.
Similar legislation has been proposed , and despite bipartisan support for versions in the and the , the bills have languished in committee without scheduled hearings. When I contacted the House Energy and Commerce Committee and the Senate Finance Committee, nobody was able to provide updates on prioritization of these bills.
Other proposals to mitigate the shortage aim to streamline the process for International Medical Graduates (IMGs) to practice in the U.S. by waiving the to return to their home country for at least after completing residency. Under current law, states are appropriated 30 waivers annually, but unused waivers are not transferable to other states and do not roll over into successive years. of the states have used all their waivers in the previous 3 years, a potential lost opportunity to integrate hundreds of IMGs into our nation's physician workforce.
Senator Amy Klobuchar (D.-Minn.) has repeatedly to increase appropriation of waivers to states that have exhausted their previous allotments. Senator Joni Ernst (R.-Iowa) last fall that avoids increasing the total number of waivers by allowing the State Department to reallocate a portion of unused waivers to states that had exhausted their allocation. Both these bipartisan bills remain stuck in committee.
Moving Forward
To be clear, there is no easy solution. Some see the current structure of GME funding as irreparable and have called for an overhaul. As far back as 1997, the National Academy of Sciences proposed the formation of a for medical education. This scheme would disperse responsibility for GME training among all healthcare payers, as they all rely upon a robust physician workforce. In 2017, the Council on Medical Graduate Education published a report recommending the creation of a "" for GME, indicating the need to consider significant reform.
While comprehensive reform might be necessary, our patients cannot wait any longer. It took over 20 years and massive amounts of lobbying to add just 1,000 new FTE spots on the heels of the COVID-19 pandemic. Legislation exists that can mitigate this crisis. Passing the aforementioned bills in Congress may be only stop-gap measures, but without prompt intervention the shortage will continue to impact access to care across the nation, especially in rural communities that are being hit the hardest.
We must move this legislation forward, make up for past mistakes, and work toward rebuilding our physician workforce.
is an MD Candidate at the Icahn School of Medicine at Mount Sinai in New York City. He is currently working as a clinical informatics fellow at RubiconMD. is a professor of surgery and medical education, and dean for graduate medical education at the Icahn School of Medicine at Mount Sinai.