Addressing the doctor shortage: More than 1,500 medical residents complete training in Michigan
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July 05, 2017 01:00 AM

Addressing the doctor shortage: More than 1,500 medical residents complete training in Michigan

Jay Greene
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    Larry Peplin
    Dr. Nashwa Khogali-Jakary goes over medical information with patient Marie-Jose-Alce at Authority Health last week.

    Nashwa Khogali-Jakary, D.O., just completed her three-year residency in internal medicine at Detroit-based Authority Health and will start a new job in September at Oakwood Health Center in Dearborn Heights.

    Tony Abood, D.O., a fourth-year geriatric fellow, spent his first three years in a family medicine residency with Authority Health. He will report for work on July 10 at a ConcertoHealth clinic at the Albert Kahn Building in Detroit.

    Khogali-Jakary and Abood are two of more than 1,500 medical residents in Michigan who have finished their training and are off to join the full-time physician workforce. About 1,500 more are now taking their place.

    The trick in a state with a doctor shortage? Keeping them here once their training is done.

    It's unknown how many of the residents will stay and practice in Michigan. No organization keeps track of that statewide. But Authority Health sees progress at keeping the physicians it trains in the state.

    Nearly half of Authority Health's 21 residents have accepted jobs in Michigan and will stay, said John Sealey, D.O., the program's director of medical education.

    "This program has done exactly what it was supposed to do; place doctors in underserved areas," said Sealey, who also is associate professor with Michigan State University College of Osteopathic Medicine and oversees Authority Health's 71 residents at four Southeast Michigan hospitals, two federally qualified health centers and several private physician practices.

    Of the nearly 300 graduate medical education programs in Michigan, Authority Health GME is one of the newest. Authority's first class completed training in 2016 with seven of 21 residents staying in Michigan. Its second class held its commencement program at the Detroit Athletic Club on June 17 and will send 10 doctors to practice in Michigan.

    "While we feel good about the quality of your training experience, we also feel good that nearly half of you are establishing your practices in Michigan and most of you will be working in medically underserved areas. This is exactly what the teaching health center program is about," said Chris Allen, Authority Health's CEO, in an address to the 2017 class.

    Approved initially in 2012 through a $21 million grant from the Affordable Care Act, Authority Health has four primary care specialties — family medicine, pediatrics, internal medicine and psychiatry — and a geriatric fellowship program. The GME teaching health center program is co-sponsored by MSU's osteopathic medicine school.

    In 2013, when the Authority Health GME program began, only 30 percent of medical students came from Michigan. This year, 60 percent are from Michigan, a number that vastly increases the chances more will stay in the state after their training, helping to alleviate the state's primary care physician shortage, he said.

    "The program was new and nobody knew much about it, so we accepted people from all over the country. As word has gotten around, more students in Michigan want to stay close to home," Sealey said. "We want to train students from the area and put them back in to our communities. Some students from other states train here and as they learn about Detroit, they want to stay here."

    Tony Abood

    Practicing in Michigan

    After sifting through more than a dozen job offers, Khogali-Jakary said she agreed to practice at the Oakwood Health Center, which is part of Molina Healthcare of Michigan, the state's second-largest Medicaid health plan with 391,000 members. She starts work in September.

    "I am very surprised" to be working at a health plan, she said. "But I am very excited about what they stand for. In my mind they are serving the underserved. These are people who don't have access to health care like private insurance. ... We are taught to offer comprehensive care."

    Born in Sudan, Khogali-Jakary moved to Lansing with her family when she was 6 years old.

    Nashwa Khogali-Jakary

    "It's always been my dream to go into medicine," she said. "I was the oldest of four kids. We were immigrants. ... We lived in communities like where I am serving now. It is very important for me to give back to the communities that gave me so much."

    Abood, who was born in Missouri, moved with his family to Michigan in 2003 and graduated from Michigan State University, didn't go on many interviews the past few months as he was winding down his medical training. He knew he wanted to start his practice in geriatrics at a clinic where he could spend more time with patients.

    So, Abood accepted the job with ConcertoHealth, an Irvine, Calif.-based primary care clinic operator with four clinic sites in Southeast Michigan, including the one in New Center where he will practice.

    "I was familiar with Concerto because I did a month there and you can spend more time with patients," said Abood, noting that Concerto specializes in complex patient populations who are primarily on Medicare and Medicaid.

    "I was looking for a place like Concerto," Abood said. "If a patient is not receiving care as they should be, with multiple hospital admissions, they send them to us."

    Big business

    Graduate medical education is big business in Michigan with more than $1 billion in state and federal funds going to the state's 88 teaching hospitals. Medicare funds about $850 million and Michigan's Medicaid program funds about $163 million. The past several years the state Legislature has considered ending Medicaid residency funding.

    The state also has the nation's seventh-largest number of residents with more than 7,200 in more than 200 hospital and other residency programs. Nationally, 1,100 teaching hospitals train about 110,000 residents and fellows each year at a cost of about $14 billion. Additional funding for residents come from hospitals, donations and grants.

    In 2013, Southeast Michigan's top three hospitals for total GME payments received were University of Michigan with more than $129 million, Henry Ford Hospital in Detroit with $96.2 million and Beaumont Hospital in Royal Oak with $57.8 million, according to a 2015 analysis by Crain's.

    At UM, about 300 residents complete their training each year with about 310 incoming interns, a number that has been growing at an annual 4 percent clip based on clinical and program needs, said Joe Kolars, M.D., UM's senior associate dean for education and global initiatives.

    Overall, UM has about 1,407 residents and fellows in training in 105 programs, the largest in Michigan. About 33 percent of its residents come from Michigan and about 50 percent of its medical students, Kolars said. Only about 5 percent of its residents are international medical graduates.

    "We have a little lag time, but the most recent numbers last year is 42 percent stay in Michigan. It has been increasing, not dramatic but an uptick in the numbers," said Kolars, adding that UM has been beefing up its primary care programs the past several years.

    On July 1, as hundreds of medical school graduates start their three- to seven-year hospital and clinic residency programs at Michigan's 88 teaching hospitals and other program sites, almost simultaneously hundreds of other residents in Michigan have completed their training.

    There also appears to be a slight uptick in residents staying in the state after their training ends, several experts told Crain's, although no hard survey data exists.

    Many residents like Khogali-Jakary and Abood who completed their training are off to join the full-time physician workforce in Michigan. Others will continue their training in a subspecialty fellowship or second specialty residency program either in Michigan or another state, Sealey said.

    But most of the young physicians going into practice in Michigan are expected to help replace some older doctors who are nearing or at retirement age. They will help ease the predicted coming shortage of physicians, especially in primary care.

    On the 11 other residents at Authority Health who decided to leave Michigan or continue their training elsewhere, Khogali-Jakary said she believes some of her friends will return to Michigan. "The majority are interested in serving the communities they trained in," she said. "Some are going for more training and hoping to come back."

    Sealey said the goal of Authority Health's teaching health center residency program was twofold. First, to contribute to the effort to reduce the estimated 2,000 shortage of primary care physicians in Michigan. Second, to provide skilled medical practitioners to care for an expanded Medicaid population under Obamacare and alleviate access problems through community health clinics.

    Because of an aging population, retiring physicians and Medicaid and private insurance expansion, Michigan may need 12 percent more primary care physicians by 2030 than the 16,200 it currently has, according to a 2015 report by the Citizen Research Council of Michigan.

    Atul Grover, M.D., executive vice president with the Association of American Medical Colleges, said data show the primary care shortage does appear to be easing — especially in states like Michigan that have expanded medical school enrollment and have large residency programs — but worsening for some specialty services like surgery, dermatology and oncology.

    "There has been an increase in the proportion of primary care physicians. We still have shortages, but smaller than in the specialties," Grover said.

    By 2030, however, the U.S. is projecting a shortage of 60,000 to 100,000 physicians, with primary care shortfalls pegged at 35,000, the AAMC said in a recent workforce report.

    But in 1997, Congress capped federal funding of residency positions to slow the federal deficit. Hospitals such as the University of Michigan, Henry Ford and Beaumont self-fund residency positions when they exceed their cap, which differs from hospital to hospital. Currently, the nation's teaching hospitals are 13,000 residents over the federal funding cap. UM currently is about 240 residents over its cap, Kolars said.

    Current bills in the U.S. House and Senate call for expanding graduate medical education funding through Medicare by 3,000 additional residents annually for the next five years. Most experts are pessimistic about the chances for Congress this year to spend $1 billion on 15,000 resident doctors, regardless of the need.

    But because teaching hospitals hire only about 27,000 first-year positions, about 9,000 medical school graduates each year fail to match in a residency program. Many try the next year, but a large number go into other fields with six-figure medical student loans to pay off.

    "If we don't get the cap raised," Grover said teaching hospitals will continue to match only about half of the U.S. IMGs, or about 2,500. "We need more doctors and adding 3,000 per year will help make a dent" in the projected shortages, he said.

    In Michigan, a 2015 federal report concluded that there are 299 physician shortage areas in the state and that Wayne, Chippewa, and Montcalm counties have the highest number of shortage areas in the state, according to the U.S. Health Resources and Services Administration.

    Creating greater access to care for patients and addressing the shortage of primary care physicians are the two main problems the Authority Health teaching health center program seeks to address, Sealey said. Primary care specialties include pediatrics, family medicine, obstetrics and gynecology, internal medicine and psychiatry.

    While most residency programs are incorporating more community medicine into their curricula, Sealey said Authority Health does more because it is designed as a teaching health center program.

    "When I was in training I would come in the back door of the hospital, stay on duty for two days and when I was done go back out the door and go home. I wouldn't stay in the community," Sealey said. "Our program really is a reversal of that."

    Authority Health residents train at DMC Sinai Grace Hospital, DMC Children's Hospital, the Detroit VA and Providence Hospital in Southfield for psychiatry. They also rotate through several private physician offices and two federally qualified health centers in Southeast Michigan — including Detroit Health Connection and Western Wayne Family Health Centers.

    Sealey said as good as Authority Health's teaching health center program is — one of 59 other programs with 550 residents funded through Obamacare and HRSA — there is a chance funding will run out Sept. 30.

    After the $230 million Obamacare grant ended in 2014, Authority Health received a two-year, $16.5 million grant extension through HRSA in 2015.

    Grover said it is likely that funding for the teaching health center program will be approved this summer because it is part of a larger $3.6 billion community health center fund reauthorization.

    "We are hoping to craft a bill with Republican and Democratic support to reallocate those funds for three to 10 years," Sealey said. "We don't know yet. We hope the program will be reallocated. ... If it isn't, Michigan State will do what it can to keep the program going or find positions for the residents."

    "Addressing​ the​ doctor​ shortage:​ More​ than​ 1,500​ medical​ residents​ complete​ training​ in​ Michigan"​ originally​ appeared​ in​ Crain's​ Detroit​ Business.

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