Teaching hospitals often make the case that a looming physician shortage justifies increasing Medicare spending for graduate medical education (GME), but recent findings by researchers indicate that there are more than enough residencies for medical school graduates.
In a recent article in The New England Journal of Medicine (NEJM) titled "Why a GME Squeeze is Unlikely,"(www.nejm.org) authors Fitzhugh Mullan, M.D., Edward Salsberg, M.P.A., and Katie Weider, M.P.H., questioned efforts to increase GME funding in Congress. They noted that such a move would only widen the gap between U.S. medical school graduates and the number of available positions, and that residency slots already are being expanded by other funding sources, many of them federal. GME funding, they wrote, should focus on the type of health care the nation needs.
"Although the GME gap will narrow slowly, it appears likely that there will be ample positions for all U.S. graduates over the next decade," the authors wrote. "It would seem difficult to argue that Congress should fund more GME positions in order to create a larger margin for U.S. graduates."
A number of residency slots go unfilled each year, and current trends show the gap between the number of graduates and the number of available positions is closing slowly. Between 2004-2005 and 2013-2014, the number of residency slots increased by 1.7 percent and the number of M.D. and D.O. graduates grew by 2.4 percent. If these rates continue, by 2023-2024 there will still be 4,500 more residency slots than U.S. medical graduates to fill them.
The excess number of residencies provides U.S. medical students with a "selection subsidy" that allows them to choose their specialty and location with greater options than would be permitted in a more competitive environment. The authors contend that international graduates, eager for medical training in the U.S., are filling many less-competitive residencies.
Such an environment does not best serve the nation's health care needs, the authors note, a point that supports the AAFP's call for GME reform that places much more emphasis on primary care. And just this week, the Government Accountability Office threw its weight behind that argument with the release of a report(www.gao.gov.) that calls for more comprehensive planning for federal programs such as GME funding to target primary care, rural workforce and other crucial needs.
Indeed, even in the absence of increased congressional funding through Medicare, hospitals are still increasing their entry-level residencies through a variety of funding sources.
"Although core dependence on Medicare funding has been a hallmark of GME, the past decade has seen hospitals steadily expand entry-level residency positions despite the Medicare cap," wrote the authors of the NEJM article.
Teaching hospitals are using additional sources of funding to expand residencies such as the Veterans Health Administration, the Patient Protection and Affordable Care Act's Primary Care Residency Expansion program, the Teaching Health Center Graduate Medical Education program, and even their own money.
The authors argue that public funding for medical residencies should not be an entitlement for graduates or teaching hospitals.
"The primary goal of public GME support, it should be noted, is to produce trained physicians to meet the country's health care needs and not to fulfill the personal preferences of individual graduates for the specialties of their choice," they wrote.
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