The Association of American Medical Colleges projects that the U.S. will face a shortage of up to 86,000 physicians by 2036 in primary and specialty care.
Building upon prior efforts in Congress to boost the physician workforce, a bipartisan group of eight members of the Senate Finance Committee released a policy outline to expand and improve upon Medicare-supported graduate medical education (GME) residency training positions in rural and underserved areas as well as in specialties facing the biggest shortages.
The AMA and other organizations are urging lawmakers to significantly increase residency slots to achieve this goal.
Rural hospitals would get infrastructure support for residency training programs under this proposal, which would also improve federal data collection to ensure that GME dollars go toward training in specialties and areas that need more physicians.
“As a bipartisan group of members of the Senate Finance Committee, which has jurisdiction over the Medicare Graduate Medical Education program, we are interested in advancing additional Medicare GME proposals to address health care workforce shortages and gaps,” says a statement from the Senate Finance Committee Bipartisan Medicare GME Working Group, which is led by Senate Finance Committee Chair Ron Wyden (D-Ore.).
In letters sent earlier this summer, the AMA (PDF) and 46 other organizations that are part of the GME Advocacy Coalition commended (PDF) the senators’ bipartisan efforts to further expand GME while offering suggestions on how to strengthen the working group’s draft proposal.
Many more slots needed
In two recent spending bills, Congress made an initial effort to shore up GME slots and strengthen the physician workforce. The Consolidated Appropriations Act of 2021 provided 1,000 new Medicare-supported GME positions, the first increase of its kind in nearly 25 years. Meanwhile, the Consolidated Appropriations Act of 2023 provided 200 federally supported GME positions for psychiatry and psychiatric subspecialty residencies.
However, more federal assistance is needed to substantially increase the number of physicians. The Senate Finance Committee working group proposes to create additional Medicare GME slots from fiscal year 2027 through 2031, stating they “would maintain other aspects of the GME allocation formula enacted” in the 2023 year-end budget deal.
A 1996 law that caps the number of physician residency positions funded by Medicare has contributed to growing physician shortages, AMA Executive Vice President and CEO James L. Madara, MD, noted in a letter to Wyden and other members of Senate Finance Committee working group. Indeed, the U.S. Health Resources and Services administration estimates that over 19,000 physicians are needed to eliminate the primary care and mental health shortage in health-professional shortage areas (HPSAs).
“To begin remedying this shortage, the cap should be removed and instead there should be consistent flexible increases in Medicare GME funding that will help to negate our current shortages while not recreating the current problems that exist with the cap today,” Dr. Madara wrote. “Additionally, we appreciate the phase-in approach to increasing the cap that is currently being utilized by the additional 1,200 new Medicare supported GME positions that were created through the 2021 and the 2023 Consolidated Appropriations Acts. We believe this metered approach to adding new slots will allow time for teaching programs to adjust and expand to provide education to additional residents.”
Primary care, psychiatry on agenda
In other provisions, the draft proposal would distribute at least 25% and 15% of new Medicare GME slots toward primary care residencies and psychiatry or psychiatric subspecialty residencies, respectively. Hospitals getting new psychiatry or primary care slots would have to maintain these slots for 10 years.
“The AMA recognizes that there are shortages of primary care physicians and psychiatrists that currently exist and understands the desire to cultivate more physicians in these specialty areas,” Dr. Madara wrote. “However, we do not believe that slots should be specialty-specific. Instead, slots should be able to go to the specialty that is in need or desired by the area. Moreover, we are concerned that by highlighting certain specialties over others it could lead to future shortages in those specialties that are not currently prioritized.”
To improve distribution of slots to rural areas, the proposal would amend the Consolidated Appropriations Act of 2023 GME-allocation formula, changing the definition of “rural hospitals” to include hospitals that are:
- In rural areas.
- Serve geographic HPSAs.
- Exceed their Medicare full-time employee cap.
- In states with new medical schools or branch campuses.
The GME Advocacy Coalition cautioned that a flawed distribution formula used by the Centers for Medicare & Medicaid Services (CMS) might deny slots to hospitals with low HPSA scores. The coalition urged the working group to include “stringent statutory language directing CMS to adhere to the distribution methodology set forth in the legislation.” The AMA, in line with other members of the GME Advocacy Coalition, also supports a less stringent distribution formula and definition of rural hospital to ensure that the newly allocated GME training positions are accessible to rural and underserved areas in need.
Support for telehealth, remote supervision
The working group should also consider provisions that would allow patients to receive telehealth services wherever they are located regardless of their geographic location, AMA Executive Vice President and CEO James Madara, MD, wrote in a letter to the Senate Finance Committee.
A study funded by the U.S. Agency for Healthcare Research and Quality reinforced telehealth as a viable alternative to in-person encounters. Examining 4 million primary care encounters, researchers at the agency found that telehealth maintained the status quo and did not contribute to health care overutilization.
“Given these insights, it is important for legislation like the CONNECT for Health Act and the Telehealth Modernization Act to pass, ensuring telehealth’s role as a cornerstone of accessible, efficient health care delivery,” Dr. Madara wrote.
The AMA also supports virtual supervision of residents in accordance with guidelines issued by the Accreditation Council for Graduate Medical Education (ACGME), which allows for audiovisual supervision of residents. Direct supervision can take place when “the supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology,” the ACGME says.
In his letter, Dr. Madara detailed a wide array of legislative approaches that the AMA supports to help address current and future physician shortages. These include measures such as:
- H.R. 2389; S. 1302, the Resident Physician Shortage Reduction Act, which would increase Medicare-supported GME positions by 2,000 per year for seven years, for a total of 14,000 new slots.
- H.R. 4942; S. 665, the Conrad State 30 and Physician Access Reauthorization Act, which would reauthorize the Conrad 30 waiver policy for an additional three years, as well as expand the total number of waivers available per state and make other targeted improvements to the program.
- H.R. 6205; S. 3211, the Healthcare Workforce Resilience Act, would initiate a one-time recapture of up to 40,000 unused employment-based visas—25,000 for foreign-born nurses and 15,000 for foreign-born physicians—so they can strengthen and provide stability to the U.S. health care system. This temporary recapture period would end three years after the bill’s enactment.
- S. 3022 the IHS Workforce Parity Act, which would amend the Indian Health Care Improvement Act to allow Indian Health Service (IHS) Scholarship and loan recipients to fulfill their service obligations with the IHS through part-time clinical practice, helping to address the shortage of physicians in the IHS.
Find out why all hands on deck are needed to confront the physician shortage crisis.
