This Fourth Report of the Council on Graduate Medical Education (COGME) provides policy makers with specific legislative recommendations which, if enacted, would establish a national physician workforce plan and approach to meet the nation's health care needs in the 21st century.
Deficiencies in the Physician Workforce
Recent data reinforces the conclusions of the Council's Third Report that the nation's physician workforce is not well-matched with public needs. Specifically, the nation has too few generalist and minority physicians, too many specialists, and poor geographic distribution of physicians. The mismatch between physician supply and health care requirements will be magnified as the nation establishes universal access to care and the system shifts to systems of managed care. In a manage care dominated health care system, the Bureau of Health Professions projects a year 2000 shortage of 35,000 generalist physicians and a surplus of 115,000 specialist physicians if current patterns of specialty choice and numbers of graduates persist.
Given health care requirements, COGME believes the following physician workforce goals should be attained by the year 2000:
If COGME's year 2000 goals were adopted and attained, the nation would produce 25% fewer physicians annually, of whom at least half would practice as generalists. This output is projected to produce a more balanced generalist physician workforce in the year 2020 and a much smaller specialty surplus. Improved minority representation and geographic distribution would significantly enhance care in many underserved communities.
Present trends are not encouraging with respect to meeting the physician workforce goals outlined above. Despite projections of a total physician and specialty surplus, the number of first year residents has continued to grow and the percentage of residency graduates choosing generalist careers has remained low. Although the percentage of minority entrants to medical school has reached a record high, the numbers are well below the desired goal. Continued increases in the ratio of physicians to population have not been associated with a reduction in primary care shortage areas.
In the long run, COGME believes that market forces created by a changing health care system will change the specialty and geographic distribution of the workforce. However, the Council does not believe that these market forces alone will produce the needed physician workforce in a timely or predictable manner. Disincentives in the "educational" marketplace, particularly Medicare graduate medical education (GME) financing policy, blunt the impact of health systems reform on the workforce. Furthermore, the nation lacks a coherent approach to invest public funds in physician training based upon health care analytic requirements. If not corrected, these deficiencies will continue to hinder efforts to expand health care access and to control costs.
COGME's Legislative Recommendations
The Council's legislative recommendations are designed to:
The proposed physician workforce legislation:
articulates the year 2000 workforce goals which were identified above
mandates funding of graduate medical education (GME) by all payers
establishes a National Physician Workforce Commission
limits total funded residency positions to the number of 1993 US medical school graduates plus 10%
allocates the reduced number of GME positions to medical school coordinated consortia
provides transition payments to hospitals most affected by the loss of resident physicians
provides incentives to individuals and institutions designed to graduate more minority physicians and generalists, to improve geographic distribution and to build primary care teaching capacity
The Council recommends that all third party payers explicitly pay for GME. Graduate medical education is largely funded by teaching hospitals from their patient care income. Both the total payment and accounting of GME funds remain unclear and are poorly coupled with physician workforce requirements. Furthermore, as teaching hospitals increasingly compete with non-teaching hospitals for participation in low cost health care plans, funding of GME may become increasingly difficult.
A centerpiece of the COGME proposal is that funds and slots would be allocated through medical school coordinated consortia. These consortia would function as "accountable education partnerships". Each consortium would include one or more medical schools and a diverse spectrum of representatives of institutions which train physicians, utilize their services, or represent the public. Each consortium, coordinated by a medical school, would collectively determine the specialty mix of residency positions based on local, state, and regional health care needs under broad national guidelines which specify the number of residency positions and mandate that 50% of graduates be generalists. Consortia would help integrate undergraduate, graduate and continuing physician education and make the educational system more responsive and accountable to public needs. Many consortia are already operating despite the absence of supportive policy.
The Physician Workforce Advisory Commission is central to the proposal. In addition to its advisory role in implementing legislative goals, the Commission would be responsible for monitoring workforce trends, workforce needs, and recommending necessary ongoing modification of goals to Congress and the Health and Human Services Secretary.
COGME believes that its legislative recommendations will achieve year 2000 goals in a timely and predictable fashion. The consortium approach will minimize federal or state government micromanagement and maximize private sector input and creativity. Incentives for individuals and for institutions will assist in the transition, helping new physicians and the medical education system respond to changing demands of the health care market place.