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IOM report on medical education questions doc-shortage fears


By Andis Robeznieks
Posted: July 30, 2014 - 8:15 am ET
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Physician organizations are not happy that an Institute of Medicine panel's vision for overhauling Medicare-funded medical training questions two beliefs that are widely held in healthcare: that a severe physician shortage is imminent and the only way to avoid it is an infusion of federal money for more residency positions.

Dr. Darrell Kirch, president and CEO of the Association of American Medical Colleges, said the IOM committee's recommendations "would threaten the world's best training programs for health professionals and jeopardize patients," while slashing funding for level 1 trauma centers, pediatric intensive care units, and burn centers.

The IOM report, written by a 21-member committee co-chaired by former CMS administrators Dr. Donald Berwick and Gail Wilensky, says shortages are created by poor geographic distribution of physicians and lopsided ratios of primary care and specialty physicians and that recent research suggests the answers lie in new technology and innovations in healthcare delivery.

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"These studies suggest that an expanded primary care role for physician assistants and advanced practice registered nurses, redesign of care delivery and other innovations in healthcare delivery, such as telehealth and electronic communication, may ultimately lessen the demand for physicians despite the aging of the population or coverage expansions," they write in the report, Graduate Medical Education That Meets the Nation's Health Needs.

While Medicare-funded residency positions have been capped since 1997, the report noted that a 17.5% increase in training slots in the last 10 years financed by other sources has not eased geographic shortages or improved the specialist mix.

"The evidence instead suggests that while the capacity of the GME system has grown in recent years, it is not producing an increasing proportion of physicians who choose to practice primary care, to provide care to underserved populations, or to locate in rural or other underserved areas," the authors wrote.

The AAMC issued a news release declaring that the "IOM's vision of GME will not meet real-world patient needs."

Dr. Janis Orlowski, AAMC interim chief healthcare officer, said the panel was right to call for more accountability in the use of Medicare dollars but argued that "a majority of reports" project a physician shortage. An oversupply of 1,000 or so physicians would not be harmful to the country, but a shortage would be, Orlowski argued.

Orlowski spoke during at a panel discussion organized by one of the report's sponsors, a medical education advocacy group called the Josiah Macy Jr. Foundation, which also included report author Wilensky.

Wilensky, an economist, countered that the argument that training a few thousand extra physicians would not add to the cost of care "could not fly."

To correct the imbalance of residency positions, with disproportionately high numbers in New York, New Jersey and Massachusetts, the report recommends the creation of an HHS GME Policy Council similar to the Medicare Payment Advisory Commission, which would develop policy for geographic distribution and specialty configuration of the physician workforce.

Kenneth Raske, president of the Greater New York Hospital Association, described the IOM's recommendations as "radical" and, if followed, would severely weaken teaching hospitals' ability to train physicians.

The report also recommends moving more programs out of academic medical centers and into community clinic settings. The American Hospital Association said this was already being done and disagreed with the direction of the report.

"The report ignores how hospitals are already addressing the changing healthcare landscape by providing training in outpatient settings such as community clinics; giving a common infrastructure to support all residents; and recognizing that some specialties, like neurosurgery, only require training in an inpatient environment," Linda Fishman, AHA senior vice president of public policy analysis and development, said in a news release.

A coalition of 20 surgical specialty societies acknowledged the geographic maldistribution but disputed the suggestion that new Medicare-funded residency positions aren't the answer. "At a minimum, Congress should bolster the U.S. surgical workforce by lifting the cap on the number of federally supported residency training positions and adopting legislation to increase the number of Medicare-supported residency positions," the Surgical Coalition said in a statement.

The coalition also said that the nation faces a shortage of 64,800 surgeons and other specialists plus 65,800 primary-care physicians by 2025.

The American Medical Association, meanwhile, projects shortages of 45,000 primary-care doctors and 46,000 specialists by 2020 and likewise argues Medicare should fund more residency slots "to produce an appropriately sized and geographically distributed physician workforce."

The American Academy of Family Physicians, which has also warned of a doctor shortage, praised the recommendations to "shift funding away from the legacy hospital-based system to more community-based training sites." AAFP President, Dr. Reid Blackwelder, his major criticism was that the AFFP wants "quicker change on a larger scale."

Author and patient safety activist Rosemary Gibson, who serves as the one non-institutional member of the Accreditation Council for Graduate Medical Education board, said the key to whether the report's recommendations take hold or are acted upon depends on whether there is a large enough constituency seeking GME reform.

"GME funding is a means to an end, and that end is training competent people to be physicians," Gibson said. "The IOM report calls for greater transparency and I think greater transparency is needed to see where the money goes, who's getting it and what they're doing with it."

Follow Andis Robeznieks on Twitter: @MHARobeznieks


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