Featured topic and speakers
The U.S. is facing a shortage of between 13,500 and 86,000 physicians by 2036—a deficiency that is almost certain to be compounded by rising rates of physician burnout and early retirement. The physician workforce, like our general population, is aging, with nearly 45% of active physicians in the U.S. aged 55 or older. Addressing the physician workforce issue is crucial to ensuring patients have access to care where and when they need it.
View this Advocacy Insights webinar on to learn about how increasing residency training slots, addressing visa issues for international medical graduates, ensuring access to care in rural areas, and addressing factors impacting physician burnout—including Medicare physician payment instability and administrative burdens—can help bolster the physician workforce.
Moderator
- Jesse M. Ehrenfeld, MD, MPH, president, American Medical Association
Speakers
- John Andrews, MD, vice president of graduate medical education innovations, AMA
- Alexis Pierce, JD, senior attorney, Division of Legislative Counsel, AMA
- Christopher Sherin, assistant director, Division of Congressional Affairs, AMA
Transcript
Dr. Ehrenfeld: Good afternoon and thank you everyone, for joining us in our latest AMA Advocacy Insights webinar series. Today's webinar is focused on our nation's worsening physician shortage crisis, the implication for patients and our health systems, and what are some of the solutions to fix it.
I'm Dr. Jesse Ehrenfeld. And in addition to being the president of the American Medical Association, I'm also an anesthesiologist in Milwaukee, Wisconsin. And so as I continue to practice and see patients, I see and experience the impact of our physician and health care workforce shortages up close.
It's now estimated that more than 83 million people in the U.S. currently live in areas without sufficient access to a primary care physician. There are large parts of Idaho, large parts of Mississippi where pregnant women can't find OB-GYNs to care for them.
90% of U.S. counties in the U.S. are without a pediatric ophthalmologist, 80% without infectious disease specialist. More than a third of Black Americans live in a cardiology desert. And in Florida, my own parents lost their primary care physician because the Medicare payment rate for doctors has plummeted over the last two decades and pushed many independent physician practices towards financial ruin.
So the physician shortage that we have long feared and warned was on the horizon, it's already here. And it's hitting every corner of this country, urban and rural, with the most direct impact, hitting families with the highest needs and the most limited means.
While the physician shortage is a crisis today, there is reason to believe it's going to get a lot worse unless we take immediate actions to address it. Think about the fact that roughly two in three doctors experienced burnout during the pandemic, according to our own AMA survey. This is the highest level of burnout we have ever recorded.
Consider that nearly half of all practicing physicians in the U.S. today are over age 55, getting close to retirement. And while medical school applications are up and some new schools are coming online, it can take a decade or more to educate and train a physician.
And when we think about physicians in large number who are already reducing their hours, contemplating leaving the profession altogether, there's trouble ahead. The latest projections from the Association of American Medical Colleges anticipates a physician shortage that could reach as high as 86,000 physicians that we won't have when we need them in the U.S. over the next decade.
And even if the actual shortfall is much less, it will still have an enormous implication for our health care system and for the ability of Americans to access the care when they need it, where they need it. Imagine walking into an emergency room in your moment of crisis, in desperate need of a physician's care and expertise and finding no one there to take care of you. That's what our patients may soon be facing.
And it's the reason why we're here today. Because there are real world solutions to this complex puzzle if we can apply enough pressure to policy makers to make the necessary changes. So with us today are three of the AMA's in-house experts to help us understand what's going on and what's needed to fix it.
I'm going to ask them to come on camera. We've got Dr. John Andrews, the AMA's vice president of Graduate Medical Education Innovations. We've got Alexis Pierce. She's a senior attorney in the AMA's Division of Legal Counsel. We've got Christopher Sherin, an assistant director in the AMA's Congressional Affairs Office in Washington, DC.
I want to thank you to our three panelists for making time for this really important conversation. Let me jump right in, John, I talked about this in the introduction, but can you please tell us in a little bit more detail about the physician workforce crisis? How has it evolved in recent years, and how did we get to this crisis point?
Dr. Andrews: Thanks, Jesse. It's nice to be with you today and with Chris and Alexis to talk about this important issue. The debate about the number of physicians in the United States has been going on for a long time. 30 years ago, the conversation was very different. In the mid '90s, there was great concern that we were training too many physicians.
And that probably related to concerns about expanding health care costs, it was a time when graduate medical education programs were capped, and there was reluctance to expand medical school admissions. Now, 30 years later, the conversation is very different.
The pressures that we're seeing now, as you noted, are an aging physician workforce, frankly, an aging population. And as our population ages, the health care needs of the population increase. And concerned about whether the physician supply will meet the health care needs of those populations.
But I want to be cautious about oversimplifying what is a complicated issue. And we need to go beyond just talking about the numbers of physicians that we're training. You yourself cited anecdotes, for example, about access to obstetric care in Idaho and Mississippi.
And by simply training more obstetricians, I wouldn't be confident that those obstetricians would go to work in Idaho and Mississippi. So there really is a need to match our physician workforce to the needs of the population.
And one of the real critical issues that we need is some sort of central workforce strategy that acknowledges what those needs are and helps us to understand how to train physicians to meet those needs, both in terms of capacity, but in terms of distribution on the specialty and geographic basis as well.
Dr. Ehrenfeld: So you work in the medical education department here at the AMA. How are you seeing this crisis play out in our medical schools and our residency programs as you look across the country?
Dr. Andrews: Well, there, I think it's a good news and bad news situation. On the good news side, the physician supply is increasing. Over the decade of the 2010s, medical school classes increased by 20%. And over the last decade, medical school classes have increased at roughly about 2.5% per year, and GME positions are increasing at a rate faster than that, 2.8% per year. There were over 1,100 new positions offered in the main residency match last year.
So the physician supply is growing, but those concerns about whom we're training and what they'll go on to do persist. At the medical school and the residency level, one of the challenges is, because of structural barriers, the way GME is financed, for example, the way clinical experience in medical school is obtained, it becomes difficult to find sites to train people in the areas that are most needed.
You mentioned primary care, you mentioned rural areas. And our current structure that supports training in large urban academic medical centers limits access to opportunities for us to create training in those areas and also to create excitement about the possibility that someone might go to work there.
Dr. Ehrenfeld: So let me bring Chris into the conversation. It's clear that this is a multifaceted issue, and one solution isn't going to be enough. What are the prongs that you see of solutions to this sort of larger workforce issue?
Sherin: Yeah. Thanks, Dr. Ehrenfeld. It's great to be here as well. Yeah, this is a multi-pronged solution that we need to have here as it relates to this particular problem. The first part is really focused on payment reform. We want to keep as many of the physicians that are currently in practice staying in practice, and that's where payment reform really comes into play.
The second part, though, is we obviously have to train more physicians. And we'll be able to do that by addressing the Medicare supported residency cap. I know Alexis is going to talk about that a little more in depth, so I won't steal her thunder right away, but that's another main part of our solution.
And the third one is, because, as we all know, it takes approximately 10 years to train a physician, even if we passed some of those GME support legislations or bills right now, we still need to do something to fill the gap. And that's where targeted immigration reform can come in and trying to increase the number of international medical graduates. So those are our three prongs.
Dr. Ehrenfeld: Makes a lot of sense. All right, so, Alexis, can you talk a little bit more about these residency cap issues that we're experiencing right now and trying to work through at a congressional level.
Pierce: Yeah, sure. Thanks. I think that John did a good job of laying out some of the big themes that we're seeing in terms of the issues that we experience with the residency and the residency cap. So I'm just going to give a little overview about what some of those things are and kind of expand on what he's already stated.
So even though the federal government isn't the sole contributor to GME, it is by far the single largest payer, primarily through Medicare funding. And as John had mentioned, Congress used to fund GME positions without the cap that we currently experience.
But in 1996, this changed because Congress decided to restrict the amount that it would contribute to physician residencies through limits on the number of resident full time equivalents and per resident amounts that it would support in the Balanced Budget Act of 1997.
So in other words, the number of positions that Medicare supported in each hospital in 1996 was established as the upper limit in terms of the number of positions or slots that Medicare would fund in those institutions thereafter. So they put it on the cap.
The cap is not absolute, as John had kind of mentioned. There are various ways that you can increase that, including through constructing a new hospital, having rural programs, start new GME programs, have urban hospitals start programs that have significant training time in rural areas, and there are a few other ways. But really, these increases aren't meeting the demand that we have.
As such, the cap has significantly impacted our physician and patient population in many ways, including not allowing for care to shift and align with the population and geographic changes that have occurred in the past 30 years since the cap was instituted.
Moreover, due to the cap, the residency positions have not been able to adapt and change as needed with our population. As U.S. medical school has increased enrollment, residency training positions at teaching hospitals haven't kept up with the larger pool of applicants because they're limited by this cap.
As a result, there's been a 52% increase in medical school enrollment since 2002. However, available residency positions haven't risen at the same rate. This lack of appropriate expansion has led to a bottleneck of medical school graduates who now need to complete their residency but don't have a slot that they can go into.
This has caused the competition for residency slots to increase dramatically over the years with the average medical school graduate in 2021 submitting 73 applications. This is a 24% increase in the average number of applications submitted per applicant compared to 2017.
This means that the average number of applications being received for each slot is more than 60. That's a huge amount. But thankfully, some progress has been made in this space. For the first time in nearly 30 years, 1,200 new Medicare supported GME positions have been added thanks to the 2021 and the 2023 Consolidated Appropriations Act.
So we're making some progress. However, it is vital that more Medicare residency positions are added so that every physician can obtain a residency slot, and so that patients can have access to the health care that they really need.
Dr. Ehrenfeld: Makes a lot of sense. Our good friend Tom Nasca over at ACGME said recently that every physician who graduates from medical school, who's capable of doing a residency ought to have a residency. And unfortunately, we know that that's just not the case because of the cap on those numbers.
So, Chris, there are a lot of bills out there in this space that get batted around that might be able to help address the issue. Can you walk us through what might be on the table?
Sherin: There's a multitude of bills, which is a good thing. The biggest bill that's out there is the Resident Physician Shortage Reduction Act. This is H.R. 2389 and S.1302. This is a bill that would allow for the cap to be removed, and then it provides 14,000 Medicare supported GME slots over seven years, so about 2000 slots per year.
And it really does build off of the progress that Alexis mentioned with the CAA in 2021 and then 2023. It's important to note, too, that this bill, it really, it tries to make sure that the slots are going to the places of most need.
Ten percent of those slots need to go to hospitals with diverse needs like hospitals in rural areas, hospitals serving patients in health professional shortage areas, hospitals in states with new medical schools or branch campuses, and then also hospitals already training over their cap.
And it's important to note, too, that a portion of these slots are supposed to be reserved for hospitals that serve health professional shortage areas and are also affiliated with historically Black medical schools as well. So it's another way to try and help with the diversity of the situation. But no single hospital can get more than 75 slots.
The other thing we're trying to push for as well is for Congress to pass something similar to the Physician Shortage GME Cap Flex Act. We don't have a bill in the 118th Congress, but we've had it in the 116th Congress. And this would really allow for GME teaching institutions to extend their cap building window for a total of 10 years. So you get five years beyond the initial five years that you would get as well.
The other bill that we also are pushing is the Substance Use Disorder Workforce Act, the SUD Workforce Act, as we typically refer to it. This bill provides 1,000 Medicare supported GME slots specifically over five years in hospitals that are in the process of establishing or will establish these residency programs in three specific areas; addiction medicine, addiction psychiatry or pain management.
In 2024, if the bill passes, it gives us 500 new slots or 500 slots for existing hospitals in those three areas. But between 2025 and 2028, we get 500 slots for those new hospitals, setting those residency programs up in those three specific areas. And again, no specific hospital can get more than 25 slots.
And then the final thing that we really need to talk about is some student loan relief. And that's where the REDI act comes in. The acronym stands for the Resident Education Deferred Interest Act. And this would really allow for borrowers to qualify for interest free deferment on their federal student loans while serving in either a medical or a dental internship.
So hopefully the combination of a relief for dentists and physicians helps with the political support for it. There's often programs out there that will allow you to defer your loans, but to get it interest free, that's the key part of this particular piece of legislation, and that's why we're so confident that it's a good bill. So I could go on for the rest of the hour here, but those are four that are really good.
Dr. Ehrenfeld: Well, that's great. It's really nice to hear that Congress is thinking about these issues. Let me transition back to Alexis and the need for immigration reform. Alexis, can you walk us through how immigration reform itself can positively impact the physician workforce and patient access?
Pierce: Yeah. And John kind of laid out some of the themes for this as well when he noted that we have an aging population. It's projected that by 2032, there will be a 50% growth in the population those 65 and older and only a 3.5% growth in those 18 or younger.
And partly due to this phenomenon, we're going to have the shortage that you mentioned at the top of the program of 86,000 positions potentially. As such, there's a growing need for a larger physician workforce, and the U.S. can't fill it on its own, in part because the U.S. physically does not have enough people in the younger generation to care for our aging country.
In 2019, the state physician workforce data report found that nationally, almost 25% of active physicians providing care in the U.S. were international medical graduates or IMGs. And building upon this, there are more than 12,000 physicians from 130 countries engaged currently in residency and fellowship training all across the United States.
In 2017, nearly 30% of medical residents in the U.S. were IMGs, with about half working as physicians in the U.S. on non-immigrant visas such as J-1s. These IMG physicians not only serve as vital members of the care team, but they've lend to diversity of thought and experience that's invaluable to our U.S. health care system overall.
Moreover, these IMG physicians play an irreplaceable role in serving patients throughout the U.S. that are most in need, with more than 20 million people living in areas of the U.S. where foreign trained physicians account for at least half of all physicians.
Furthermore, foreign trained physicians are more likely than U.S. trained physicians to practice in lower income and disadvantaged areas, as demonstrated by the fact that over the past 10 years, more than 10,000 J-1 IMGs have worked in underserved communities.
However, the physicians experienced numerous immigration hurdles that they have to overcome throughout their career. When J-1 physicians were surveyed by ECFMG in late 2019 and asked to describe the challenges to their well-being, almost 8,000 physicians noted that fluctuating immigration laws contribute to a unique set of stressors for them.
Further, 63% of male respondents reported that visa and immigration concerns were among the top issues impacting their overall wellness. This isn't surprising, since each administration can enforce immigration laws very differently.
However, if smoother pathways are created for IMGs, there will be significant positive impacts for the U.S. health care system, since immigration reform could help to ensure that our physician workforce is able to adequately meet the needs of our population.
Moreover, if key immigration reform efforts were enacted, we could ensure that our U.S. trained IMG physicians are able to remain in the United States and continue to care for their patients, build up practices, and have personal stability. Finally, physician immigration reform could help our country ensure that our underserved populations have access to physicians.
Dr. Ehrenfeld: Well, clearly, our international medical graduates are such an important aspect of the physician workforce. And I also just have to comment that my own pediatrician growing up was an international graduate from Venezuela, and my internist, when I got a little bit older, was an international graduate from Ireland, and they were two of the most incredible doctors I have ever met who inspired me in many ways to go into medicine.
All right, let me back to Chris. Are there any bills in the space that might help out our international graduate colleagues?
Sherin: So, Dr. Ehrenfeld, I'm sure you'll be surprised to hear that there are a multitude of bills related to this particular area. And I think it's important to note, too, that this is just one prong of the approach. There's been some comments in the chat that we're receiving about replacing U.S. IMGs. This is just a complementary piece of it. So I wanted to be clear on that part.
But one of the biggest bills that we support as it relates to the IMG prong of our solution is the Conrad State 30 and Physician Access Reauthorization Act. So physicians come to the United States on a variety of different visas. But the most commonly used visas, the J-1 visa.
And this is a very versatile visa. And what I mean by that is it's applicable for all different types of individuals. So you'll have government visitors, you'll have professors, you'll have au pairs. But there's also this category of alien physicians as well.
And the way the J-1 works is, you come to the United states, you're supposed to complete your unit of study or work, you sharpen your English skills, and then you're supposed to go back to your country of origin for two years before you're allowed to apply for a new visa or green card.
So when this was set up, it's designed for individuals to essentially go back and spread the good news of the United States, which makes a lot of sense for professors and au pairs and other individuals. But for the specific category of alien physicians, it's a huge missed opportunity.
So what Senator Kent Conrad did back in 1994 was he created this program that allows for each state in the country to get 30 waivers to issue to those J-1 physicians. So you do not have to go back to your country of origin for two years in exchange for working in an underserved community, a health professional shortage area or a medically underserved area for three years.
And every state in the country has utilized this program since its inception in 1994. The program just basically had its 30th birthday. What we're trying to do, though, is because it's been 30 years, we need to make some targeted improvements.
So our bill would reauthorize the program for three years from the start—from the date of enactment, get off of the appropriations cycle. It also creates a process to increase the total number of slots from 30 to 45. We'd never go below 30, but it would incrementally increase it up by units of five as long as the states continue to fill their slots.
And then it also includes some really important transparency provisions as it relates to the contracts that the physicians have to sign. To me, though, the most important part and the most interesting provision in the bill is if you're willing to serve in an underserved community or a VA facility for five years, you get the opportunity to get expedited consideration for a green card.
Our bill intentionally does not touch the total number of green cards that are issued, nor does it touch the per country green card cap. But it does, for especially Indian and Chinese physicians who have to wait quite a long time to get one of these green cards, it allows you to get to the head of the line.
And if you're willing to serve in those underserved communities or VA facilities, it's a real nice trade off. This is a benefit for all physicians. I think the most important thing, though, is the three years that you would serve as a Conrad physician, that would count towards your five years overall.
So that's one of the big bills that we have out there. It's doing very well in the House. It has close to 100 co-sponsors and 23 in the Senate. We also have a couple of bills that would make some changes around the edges to Conrad 30, which we think—well, we do support that standalone bills are best served to be added as an amendment to the Conrad 30 legislation I just described.
One of them is the Doctors Act, which starting in 2025, would consolidate the unused Conrad waivers and allow them to be redistributed for an additional fiscal year to those states that are already using all of their waivers. So it really allows for those precious waivers to not go unutilized.
And then we also have another bill called the Doctors in our Borders Act, which is just in the House. It's represented by Mike Lawler and Shri Thanedar. And that bill would allow for J-1 visas, the waivers to increase from 30 to 100. That would be the number that's given to each state. So we'd start referring to it as the Conrad 100 program, which would be a nice thing to say.
Outside of the Conrad 30 program, we also have the Health Care Workforce Resilience Act. Now, this bill would recapture 15,000 unused employment-based visas for physicians. It also would recapture 25,000 of those for nurses. It's another great bill. These unused visas would be from 1992 to 2021. And if the bill passes, we get a three year period to recuperate those.
So I think you take the combination of those three bills, and you can see that there's a wealth of solutions out there that Congress should pay attention to, and we're pushing them very hard to make those changes and enact those bills as quickly as possible.
Dr. Ehrenfeld: Well, thanks, Chris. I hope that we can get some of those really important pieces of legislation passed. It never has made any sense to me that an international graduate can come practice under a J-1 visa, learn our systems, learn all of the workarounds, the frustrations of dealing with prior authorization, figure out how to navigate getting people the care that they need, and then we require them to leave for two years before they can come back. It's just irrational.
So even if those pieces of legislation that you talked about are passed, it's not going to matter if we can't keep physicians in practice for the long-term. So, Chris, talk us through how payment reform is also such an important long-term piece to make sure that we maintain and build a strong physician workforce.
Sherin: Certainly. And it's really quite simple, Dr. Ehrenfeld. We need Congress to pass legislation that's going to enact comprehensive payment reform, because as I mentioned before, we need to keep as many of those physicians that are currently practicing to stay in practice. And how do we do that? We need to make some real targeted improvements to the physician payment system.
Now, most of you on the webinar will recall that we were successful in getting some of the most recent cut mitigated, not all of it. There's a 3.37% cut that actually did go into effect in full for a few months on January 1 of 2024.
Well, Congress was anticipating that cut coming down the line again, and they did pass in the Consolidated Appropriations Act a 1.25% increase to the conversion factor. But that was gobbled up, and we were really stuck with that 3.37%.
So AMA as well as the other members of the House of Medicine and all of you on the webinar that sent those emails, made the phone calls, did the shoe leather lobbying came together, and we were able to get an additional 1.68% increase to the conversion factor in the Consolidated Appropriations Act of 2024, which was passed in March of this year.
But I want to emphasize that that is not a solution, and this was just a piecemeal approach and it didn't even solve the entirety of the cut. So what are we doing at the AMA to try and provide that long-term solution? We have a bill, H.R. 2474, it's the Strengthening Medicare for Patients and Providers Act. This is our legislation that would provide physicians with a permanent annual inflationary update in Medicare, and it's tied to the Medicare Economic Index.
So that gap chart that all of you have seen and likely used on Capitol Hill would close in terms of what we are being paid over the last 20 years as physicians and what physicians are being—what the cost of running a practice as measured by the MEI really is, it closes that gap. So that's a huge part of this another three-prong solution.
The other part that I want to emphasize is Budget Neutrality Reform. And this is H.R. 6371. This is the Provider Reimbursement Stability Act. And as you know, many of these particular cuts that we're faced with are stemming from budget neutrality and the Medicare physician fee schedule.
The threshold has not been increased from $20 million since it was enacted in legislation from 1988 and really 1992. So the first part of our bill would increase that threshold from 20 million to 53 million. And it also would allow us to get away from being stuck with that specific figure because we would index that figure for inflation. It would be the cumulative MEI over five years that would increase that $53 million.
The other part of the bill, though, that's really important is the look back. It requires whenever there's a code that receives a utilization estimate from CMS, that particular code would then have to be reconciled against actual claims data over a two-year process.
So whenever the conversion factor is altered as a result of those particular changes that stem from utilization assessments that quite frankly are usually incorrect, we're going to now do something prospectively about that. We're going to say the utilization assessment is not accurate, you can compare it to the claims, and therefore the conversion factor needs to be updated prospectively.
So it's a great way to try and make sure the fee schedule stays accurate. The best examples are things like the chronic care management codes, the transitional care management code, even the G2211 that just went into effect for inherently complex patients for evaluation and management services. These are the things that we're going to double check CMS on.
The other part of the bill too, is it would provide a standardized calendar in terms of practice expense RBUs and the direct inputs and how they're reviewed by CMS. Things like clinical wages, prices of medical supplies and prices of equipment, they're going to be reviewed no later than every five years.
So we're not going to have the clinical labor situation after 20 years that created a lot of unrest in the physician fee schedule, or the changes to equipment that also happened for the first time in 20 years most recently. So that's a very important standardized calendar that we have.
And then you'll see a provision in the legislation that would stop any sort of swing in the fee schedule by more or less than 2.5%. In other words, the conversion factor can't go up and down by more than 2.5% in a given year, really helping us get away from those wild swings.
That's our Budget Neutrality Legislation. That's the second part of our payment reform strategy. The final thing, too, I'd be remiss if I didn't mention this. We have a very close to unveiling legislation that would provide real reform to the MIPS program. It would get rid of the tournament style. So high performing physicians are not being supplemented by poorly performing physicians in the MIPS program.
We would improve the measures assessment process. And we would also ensure that physicians have access to real-time data. And if CMS fails to provide that data to physicians, they would not be subjected to those annual cuts as well. So it's another way to really force CMS' feet to the fire on this.
So when you think of it, it's another three-pronged approach to this particular problem; MEI, budget neutrality and MIPS reform. If we can enact all of those particular pieces of legislation, undoubtedly we'll be able to keep the current population of practicing physicians in business, which is so important to solving this workforce crisis.
Dr. Ehrenfeld: Well, speaking of payment reform, we are hosting our next AMA Advocacy Insights webinar on June 4. It's going to be a mid-year update on the Medicare physician payment and what we're doing, and we'll drop a link to registration in the chat.
Let me transition back to these important bills, though, Chris. What's the political appetite to get any of these things advanced? Have you seen any recent action in Congress that we can maybe be excited about?
Sherin: Yeah. The best thing about these issues, they're largely nonpartisan issues. Now, immigration obviously has some partisan tinges to it, but even in that context for our issue, it's a workforce issue. But when it comes to payment reform, we've seen a lot of inertia on the Hill.
We've seen hearings last year in the Energy and Commerce Committee. We've seen a hearing in the Senate Finance Committee last month. We've seen a white paper released by the Senate Finance Committee. We've also seen a working group formed together, and AMA participated in that just recently providing ideas, the same ideas I just laid out on MEI and budget neutrality and MIPS reform.
Tomorrow, we're going to see the Ways and Means Health Subcommittee look at physician payments. The House Budget Committee tomorrow is also going to look at consolidation and physician payment issues. So a lot of inertia. I will say this. I don't want to over promise here. And my crystal ball is still a little bit hazy as it relates to what's going to happen at the end of the year.
But I will say that a lot of it's going to depend on what happens in the elections here. And I think we all agree that the United States needs to have an election. We need to figure out who's going to be in control of both chambers for two years. We also need to figure out who's going to be in control the White House for the next four years.
Once that shakes out, we'll have a better sense of what the Congress wants to do in addition to what the either new or continuing Biden administration will want to do. Then we start looking at offsets. And when the offsets are available and you see who's in control, we'll have a better sense of where things come.
But I think it's undeniable that there's some inertia behind these particular issues. And we'll see something in the lame duck session. And that also holds true for the GME legislation as well. It always comes down to cost, but there's a strong support to try and do something on that.
We've seen the health committee put out a lot of different proposals, and obviously the Resident Physician Shortage Reduction Act is always a central part. So I think we've got some confidence here, and we've just got to see how things shake out and continue to press the case.
Dr. Ehrenfeld: Well, speaking of seeing how things shake out, obviously, I do want to make sure to remind folks that the AMA is a nonpartisan organization. We work with all elected officials on both sides of the aisle. And regardless of who is in the White House and who is controlling the chambers in Congress, sometimes it just provides different policy opportunities for us based on those priorities. And there's no shortage of things certainly that we need to do.
Let me bring John back into the conversation. So addressing the workforce shortage is also an important health equity issue as well. So how are these workforce shortages impacting in particular underserved communities across America?
Dr. Andrews: Well, Jesse, I think you answered that question in your introduction with the anecdotes you shared about access to care, cardiologists, obstetricians, your parents. The inability to access care is in and of itself a health inequity.
But more importantly, when access is compromised, it leads to delays in care, delays in obtaining care that lead people to more advanced stages of disease when they ultimately find appropriate care. And that leads to inequitable outcomes. The populations that suffer these limitations in access are the very ones that are suffering much worse health outcomes as a direct result of their inability to be cared for by the physicians that they need.
Dr. Ehrenfeld: So, John, there's a lot happening within the medical education unit at the AMA. Can you walk us through some of the projects in the ChangeMedEd initiative that you're involved in that are trying to address this workforce issue in particular, and how some of those efforts might be linked to some of our work in health equity?
Dr. Andrews: Sure. I'll mention a couple of them that I'm quite familiar with just as examples. I oversee an initiative called Reimagining Residency, which is working to innovate in the graduate medical education space. And one of the projects that we support is a collaboration between UC Davis and the Oregon Health and Sciences University to address workforce shortages in communities between Sacramento, California and Portland, Oregon. Many of those areas rural, and many of those communities indigenous.
And the model that they're evolving is to reach into those communities to recruit people into careers in medicine to serve the needs of those populations because they know they're the very people who are most likely to return to those communities to serve.
And then during their education in medical school and importantly in residency, they're delivering that education in those communities so that people are training in the environments where they'll have familiarity with the resources that are necessary to provide effective care.
And so we think that shows a lot of potential for serving the needs of those communities with people who are culturally and in many cases racially and ethnically concordant with the populations whom they would serve. On the other coast, there's a project at the University of North Carolina called the Fully Integrated Readiness for Service and Training project.
This is an evolution of a pilot they've had for a while that attempts to truncate training for people who are committed to careers in primary care. So they have a three plus three plus three model. Three years of medical school, followed by dedicated transition to three years of residency and family medicine, and then three years of mentored practice in a rural community in North Carolina, once again working to meet those workforce needs.
And with our support through Reimagining Residency, they've expanded that model to other disciplines, including surgery, pediatrics and psychiatry to address deficits in access to care in those disciplines as well. That is shortening the time to get these people working in those communities and importantly, providing them a dedicated path to careers that they aspire to.
Dr. Ehrenfeld: Well, Alexis, John, Chris, what a great discussion. I want to now open it up to our audience for questions. If you've got a question for our panel, if you haven't already, please add your question to the chat, and we'll get started now.
We've got a couple of questions that were presubmitted earlier in the week. Let me start with one of those. How do we incentivize more physicians to train and/or practice in rural and underserved areas?
Dr. Andrews: Well, I'll leap in and just say that I think incentives are important, but I want to fold back on this strategy that I talked about earlier, which is to think about whom we're training, and where those incentives from a background standpoint come, in addition to any sort of financial or loan forgiveness incentives we might offer for practice in those communities.
I think we need to think really carefully about whom we're training and whether those trainees are likely to meet the needs of the communities that most need them.
Pierce: Yeah, I agree. Sorry. Maybe I could—yeah, so just expanding on that, I think that that's right. Whenever we're advocating with the administration or on the Hill, we look at this problem holistically.
And we advocate for everything from starting integration and knowledge about being a physician to elementary school students to asking them to think about mentorship and how that might look through high school and college and through the application period for medical school, and all the way to having communities play a more active role in how they promote and talk about the physician profession.
And then, of course, we talk about it all the way through funding. So increasing access to things like the National Health Service Corps and expanding that to additional practices that can be involved there. They've recently expanded it to OBs, which is fantastic with maternity care target areas. That's something that we pushed for.
And all the way through to the very core of how public service loan forgiveness is enacted. And we worked really hard to make sure that even physicians who weren't directly employed by their employer, so for example, in Texas and California with the corporate practice of medicine, that they can still access those beneficial programs.
And of course, we touched on those same similar service programs through the Indian Health Service and a few other—the veterans service, those few other things. So we think it's really—we try to address it all the way through. And then, of course, keeping them in practice, like Chris had talked about, with fair payment. So yeah, thanks.
Dr. Ehrenfeld: I think this next question is for Chris. It's a long one. How does the CBO score of H.R. 2474 impact its political viability challenge no doubt, but Congress has the entire federal budget that it pull from. Where do you see this going?
Sherin: Yeah, so this was actually my attempt to answer that particular question that I got. So you're exactly right, the questioner is in terms of what is the political challenge. We don't have an official CBO score, and it is a costly bill, but it's not insurmountable as it relates to the MEI.
And really what I want to emphasize is that AMA isn't typically in the business of selecting offsets for these types of pieces of legislation. That's largely why Congress is there, and they have the entire federal budget at their disposal. And there is plenty of money that they can pull from if necessary.
What I will say, though, is that it is a challenge. But even if we can get, say a two or a three-year down payment, if you will, on an MEI, that does serve as a springboard for permanent reform. And I think we just have to recognize that particularly in this particular climate, we have to operate within what's possible and what's readily available for us and that's what we're trying to do as best we can.
Dr. Ehrenfeld: That makes sense. So obviously, we're the AMA, we work at the federal level, but we obviously all work with our state partners and the rest of the Federation of Medicine. Let me bring it down a level and ask, what can state policymakers do to piggyback on some of those solutions we've talked about to try to address some of these physician shortages?
Dr. Andrews: I think Alexis and Chris can speak to their legislative responsibilities. But one of the important things I think we need to recognize is that many of these disparities are regional. And people at the state level are probably in the best position to understand what the needs of the populations are locally.
And I think a central federally supported solution to many of these problems is going to be less effective than people who are on the ground in those communities and know what the needs are.
Dr. Ehrenfeld: Chris? Alexis? State policy options that might help us.
Pierce: I think that obviously states can and have enacted their own recruitment programs as well as their own repayment programs. Additionally, states can fund their own residency slots if they so choose to. And multiple states have chosen to do that.
We have a GME compendium where we have a kind of collation of some of these efforts. So if you are interested in that and you have some sway with the state or you work for your state, I would encourage you to maybe take a look at that as a starting point, because you can see how other states have successfully integrated and implemented some of these systems within to their own health care system.
And John's right. So that way, you at the state level can target your needs, and you can put in requirements to either work in certain areas or promote certain specialties that you're seeing that are particularly needed in that area. And I think that actually you have a ton of control at the state level to try and help some of these underserved areas or deficiencies that you might be seeing locally.
Dr. Ehrenfeld: Chris, other thoughts?
Sherin: I think that's very well said. I don't have a whole lot to offer in addition to that. I do think the fact that states can try and fund their own residency programs is hugely important. Obviously, they have their own budgetary constraints as well that they have to operate under, but it is an important fact that often gets overlooked.
Dr. Ehrenfeld: So let's stay at the state level. What can our medical societies do around the nation to help with some of these physician shortages? Are there any particular type of collaborations that you all see as most helpful or useful or productive?
Sherin: I can jump in a little bit on this one. I think as it relates to the bills that we've described, whether it's the Resident Physician Shortage Reduction Act, the REDI act, the SUD Workforce Act. The states can get involved as it relates to grassroots advocacy, pushing for additional co-sponsors, pushing for legislative action on this.
So often, federal elected officials want to hear from folks back in the state and local districts, and that's where you can play a real great role in this. You also are so adept at localizing these issues. Individuals like me will often talk about the federal impact and just the nation in general.
What the elected officials want to hear about is how it's going to impact them on the local level, and that's where the states can be so invaluable. So those are the things that I would suggest for the states to get active in as it relates to this workforce issue.
Dr. Ehrenfeld: Makes a lot of sense. So let me ask maybe a pointed question. Is better compensation and less charging electronic health record the answer to our physician workforce shortage problem?
Sherin: So I think that's—it's an interesting way to say it. And this is, again, where I'm talking about the localizing, the personalization of these particular issues. A member of Congress or even on the state level is probably not going to know a whole lot about charting. But what they will understand is administrative burden, and I think you can stress that that's one part of it.
When it comes to compensation, I think it's very clear that we need to do something about Medicare Physician Payment Reform. And that's compensation. And so you take the combination of the three bills that we described on Medicare Physician Payment Reform, as well as burden reduction, things like prior authorization, step therapy, those are things that will undoubtedly help the workforce crisis because it'll eliminate burnout, and it'll also keep the existing population of practicing physicians in the practicing setting, and that's what we really want.
So that's what I would advise that particular questionnaire to do.
Dr. Ehrenfeld: Let me ask John this next question. How do we make sure that our new physician workforce, our growing physician workforce is racially diverse and able to meet the needs of the communities that they serve, particularly given some of the challenges around the ending of a lot of affirmative action programs with the Supreme Court ruling last summer?
Dr. Andrews: Yeah. So I don't want to sound like a broken record, but recruitment efforts are important. Again, we need to make sure that we're reaching out to train the right people. And many of the institutions with whom we're partnering in our unit are adopting some very creative approaches to look at distance traveled to a career in medicine that are independent necessarily of objectification of race and those sorts of things.
So I think we need to get the right people into medical training, but importantly, we have to create paths to success for these people as well. We know there's differential attrition from our training programs among certain groups. It's a particular problem among Black men, where attrition from residency far exceeds the rates for other groups.
And there are some cultural and structural issues in our medical education programs that need to be addressed to ensure that someone who pursues a career in medicine is going to be successful and ultimately serve the populations that we hope they will.
Dr. Ehrenfeld: Well, speaking of Black men, I will say that one of the most magical functions that I've been a part of locally was a Black Men and White Coats Youth Summit that we hosted in Milwaukee at the Medical College of Wisconsin two weeks ago.
600-plus kids and their parents registered to come. Sixth graders on up learn about going into the health professions to hear from folks that look like them, to see that they can be in the health professions, medicine and others. And I think those opportunities to really open people's eyes and make sure that people who have the capability aren't pushed away because they don't consider the possibility or they haven't seen somebody who looks like them in medicine.
Let me ask this next question. How do we affect a performance-based standard with ACGME or ABMS to shorten the time to certification so that we get more talent out on the front lines sooner and out of these time-based approaches to training?
Dr. Andrews: Yeah, that's—we are very time bound in medical education. And so one of the structural barriers we have to address is the fact that the current currency for licensure or certification in medicine is the time spent in training rather than the competency achieved.
And so we're working hard to develop reliable measures of competency that we can advance to say, I know someone's only been in training for a certain period of time, but they're ready for independent practice. We're not there yet to a level that's acceptable for things like state licensure and board certification, but that work is ongoing.
I will highlight, however, that there are paths that already exist for committed learners. There's a consortium of accelerated medical pathway programs that offers three-year pathways from medical school into certain residency disciplines. For example, I described the first program in North Carolina.
So there are some people taking some practical steps to do that. But time variability is a big issue in medical education right now that really rests squarely on the shoulders of assessment.
Dr. Ehrenfeld: There's a question that popped up that's about our international medical graduates. And the question, which we may not have specific answer to, but I think the idea is clear. What percentage of IMGs coming to serve in an underserved area then go on to a better paying specialty training or job somewhere else after they do what is maybe required? Do we have any sense of that?
Pierce: Yeah. I was trying to dig for the exact numbers because I have it somewhere, but really the retention rate is really high. They tend to stay in the same area where they've been serving after the Conrad 30 program, or if they engage in some other sort of waiver program through like the HHS, the VA, whatever it might be.
And it's significantly higher than their U.S. born counterparts, because they tend to integrate into the community. They stay, they build a practice. And really, so these programs, these waiver programs have been extremely successful and more successful for IMGs than for native born physicians. So I would say that, yeah, the stronger we can make them, the more likely we are to have them integrate permanently.
Dr. Ehrenfeld: It makes a lot of sense. And it's sort of where you land and where you get set up and where you get integrated into the community is so important. We certainly see that as we think about creating some of these rural training opportunities at the GME level.
The data that I'm aware of is that 80% of residents will practice within 80 miles of where they do their residency training. So if we are able to expand those rural training pathways, obviously there may be some additional benefits.
This next question is long, and I think there are a couple parts. So let me take it piece by piece. The first piece is, how is the AMA presently advancing equity for those underrepresented in medicine, clinicians who are in training and in the workforce today?
Sherin: Yeah, so it's a great question. We are advocating for a more diverse physician workforce. I think the Conrad 30 legislation is part of it, because if you have international medical graduates who are not born in the United states, did not go to an American or Canadian medical school, and they come to the U.S. for residency and then they're allowed to stay, as we've just described, it's very likely that they're going to stay in those rural communities.
So not only does it help with the workforce crisis, but it diversifies the physician workforce, which is so important. There's also different parts of the bills that I've described that are trying to focus on this particular issue. The Resident Physician Shortage Reduction Act, for example, has a GAO study mandated in there to try and look at how we can get more minoritized and marginalized populations within the physician community.
And it also tries to talk about strategies for that, too. So I think the combination of some of the bills that we're already referencing, as well as some of the components that maybe are less known in the bills that I've described are ways to do it.
You also can talk about the connection with the historically Black medical schools as it relates to where those residency slots would go. So I think the combination of those things are really great ways to show how we're fighting for a more diverse physician workforce.
Pierce: And we've also—
Dr. Ehrenfeld: The next part of this question—Oh, go ahead, Alexis.
Pierce: No, no, no. Go ahead. It's OK.
Dr. Ehrenfeld: No, I just said the next part of this question is I think asking how do we balance or prioritize advocating for recruitment of more international trained physicians into the U.S. while also thinking about how do we get fair treatment of our U.S.-based, U.S. born underrepresented physicians?
And I would say that it's not either or, it's both. We have to do both. And we would never think about prioritizing one versus the other. It's full stop, we need both and we won't stop until we achieve it. But Alexis, maybe you wanted to jump in.
Pierce: No, that's OK. I totally agree with what you said. I think it's a both approach. We need all hands on deck. We've talked about the shortages we're going to experience, our aging population. So our shortages might grow, actually. And I think that we want to advocate from a holistic perspective. So just echoing what you said.
Dr. Ehrenfeld: Perfect. Well, we're getting close to the end of the hour. I do want to give each of our panelists just a minute to provide any other summary comments on priorities that they see in the years ahead, and then I'll give us some closing comments. And maybe I can start with Alexis and then go to John and then end with Chris.
Pierce: I think it's just we are truly working holistically to try to address this from every single angle. For underrepresented physicians who are born in the United States, for international medical graduates, for practicing physicians.
And we take on that in almost every single statement that we submit to the administration, to the Hill. And I think that if you do take some time to go through our Letter Finder, you will see that we've looked at this from so many different angles, and we support a plethora of bills and rules and proposed rules that we didn't even get to touch on today because of the time constraints.
So I would really encourage people who are on this webinar and want to learn more to go and look through Letter Finder and also to look at our Graduate Medical Education Compendium and to look at some of the great work that John Andrew's team is doing on our MedEd portion of our website. And thanks for spending the time with us.
Dr. Ehrenfeld: And we'll see if we can get that link to the Letter Finder in the chat for people to easily reference. John, any closing thoughts?
Dr. Andrews: Yeah, thanks, Jesse. I just … I'm going to reiterate something I said at the top of the conversation, which is to not reduce this to a simple capacity issue. It's really a geographic and specialty distribution issue as much as it is a supply issue.
And at the risk of countering a point that was made earlier, there's plenty of capacity in our GME system right now. There's a lot of talk about the fact that GME is a bottleneck, that there aren't enough residency positions for U.S. medical graduates.
There are 1.4 positions in the residency for every U.S. DO and MD grad right now. There's plenty of opportunity. But the individual choices that people are making about what—about where they train and what they train in are influencing U.S. graduate engagement with the workforce. And I think that's where we've got some work to do.
Dr. Ehrenfeld: Well, certainly, as I am AMA president and out there on the road, everybody wants to be an anesthesiologist, which doesn't perhaps help. All joking aside, that is an important point about that mismatch between what's available and what we have the capacity to provide. Chris, closing thoughts.
Sherin: All I can provide is that I think we as the AMA are trying to put forward real concrete solutions. And as John mentioned, it's not just simply a capacity issue, I think this is a multifaceted issue that requires a lot of different types of solutions. And you've heard from us about the different ways we're trying to tackle this.
We can't just look at it from training more physicians, we can't just look at it from targeted immigration reforms, we also have to incorporate payment reform. If we can achieve all three of those things, I think we're in a great spot. And I think we're serving the membership well by looking at this issue a little more holistically and beyond just the narrow focus of trying to train more physicians.
Dr. Ehrenfeld: I think that makes complete sense. And the good news is we've got some of the brightest, hardest working people in the universe focused on this, including the three panelists: Chris, John and Alexis, each and every day trying to bring forward these solutions.
Unfortunately, that's all the time we've got for today's webinar. But I want to, again, thank you all for being such wonderful panelists and all those who dialed in for the great questions that we got. The physician workforce trends that we went through today are really concerning to everybody who works in health care and to everybody who relies on the health care system to recover from an injury, get through an illness. That means everyone.
But the situation is clearly not hopeless. There are real solutions out there that we can help grow and strengthen our physician workforce to meet the health needs of a changing America. I want to thank everybody for your time today and for being so engaged with us on this issue. And I would hope to invite you to join on June 4 for our next AMA Advocacy Insights webinar on Medicare physician payment. Until then, be well, thank you.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
