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2012: The Year in Review
Need for More FPs, Changing Demographics, Threatened GME Funding Key Education Issues
By Nancy Kuehl
Filling the FP Pipeline
Students seemed to gradually be getting the message, as well, and the family medicine match rate once again ticked upward, albeit only slightly. In 2012, the fill rate for family medicine residency programs improved only by 0.1 percent compared with 2011, which saw a record-high fill rate of 94.4 percent.
It's not enough, said (then) AAFP President Glen Stream, M.D., M.B.I., of Spokane, Wash. "Family medicine is the foundation of improved health care in this country," said Stream. "We must continue to promote programs that generate and sustain student interest in the specialty."
AAFP Report Focuses on Scope of Practice
The AAFP points out in the report that "the best, most efficient (health care) is provided by teams of health professionals in the patient-centered medical home (PCMH) led by physicians, not independent practice by a single nonphysician health professional."
Although NPs are a vital part of the health care team, "they cannot fulfill the need for a fully trained physician," says the report. Efforts by NPs to set up independent practices will undermine the ability of primary care physicians and PCMHs to deliver team-based care.
"The PCMH model improves the quality of care because it capitalizes on the unique expertise of each member of the patient's health care team," said (then) AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, Texas, in a press release. "It ensures patients are under the care of a physician and expands access to health care services.
"Wholesale substitution of nonphysician health care providers for physicians is not the solution, especially at a time when primary care practices are being called upon to take on more complex care. Patients need access to every member of their health care team -- starting with a primary care physician, nurse practitioners, physician assistants, and all the other professionals who provide health care."
"A crisis in access to first-contact, comprehensive and coordinated medical care is occurring in the United States," said another study by authors from the AAFP's Division of Medical Education. The bottom line, they noted, is that the family medicine workforce is not growing at a rate sufficient to meet the country's needs.
However, one bright spot in 2012 was the increasing number of osteopathic students who chose family medicine. Graduates of colleges of osteopathic medicine filled 706 first-year positions in July 2012 compared with 633 in 2011 and 599 in 2010.
According to the study's authors, those numbers likely will continue to rise because of the growing enrollment numbers at current and newly accredited osteopathic medical schools in conjunction with an increase in the number of dually accredited family medicine residency programs. There were just 26 such programs in 2003 compared with more than 113 in 2012.
In addition, according to the Association of American Medical Colleges (AAMC), U.S. medical schools are seeing a steady increase in first-year enrollment. AAMC President and CEO Darrell Kirch, M.D., said that U.S. medical schools have been doing all they can to address a serious future physician shortage.
According to an AAMC survey, it is anticipated that first-year medical school enrollment will reach 21,376 in 2016-17, which is a 29.6 percent increase compared with first-year enrollment statistics from 2002-03. In addition, 43 percent of schools surveyed said they had targeted or planned to target increases in enrollment to specific population groups or to meet the needs of underserved communities.
But more has to be done, said the AAMC, pointing out that without increases in funding for residency positions, efforts to increase interest in primary care could be wasted. In a white paper released in September, the AAMC stressed that "the United States cannot afford to wait until the physician shortage takes full effect, because by then, it will be too late."
The organization recommended
- increasing the number of federally supported graduate medical education (GME) training positions by at least 4,000 new positions a year;
- basing funding for new residency positions on population growth, regional and state-specific needs, and changes in delivery systems, with half of the new positions being allocated to primary care and other generalist areas;
- using clinical reimbursement and other mechanisms to affect geographic distribution of physicians and influence specialty composition; and
- continuing to invest in delivery system research and evidence-based innovations in health care delivery.
A Changing Demographic
"The great majority of final-year residents surveyed, 94 percent, would prefer a straight salary or a salary with production bonus in their first year of practice," said the survey. "Only 2 percent would prefer an income guarantee, a type of compensation structure usually offered in independent rather than employed practice settings. This reinforces the fact that residents today are not particularly entrepreneurial and would rather earn a paycheck initially than assume the financial risk of practice ownership."
Merritt Hawkins cited the uncertainty in the health care world created by changes in all aspects of health care in the United States as one reason for the shift to salaried positions. But other factors played a role, as well, including the difficulty of purchasing an electronic health record system for small practices and the cost of repaying education debt.
However, according to the AAMC, education debt levels for medical students have been holding steady. In 2011, 86 percent of medical school graduates owed a median amount of $162,000 in education debt, which breaks down to monthly payments of $1,500 to $2,100. That median amount was only 3.1 percent higher than the median amount of education debt in 2009 ($156,500).
And another study from the AAMC in 2012 concluded that primary care is a financially viable career choice for medical school graduates with median levels of education debt. However, students graduating with higher debt levels may need to consider additional strategies to support repayment.
GME legislation was again at the top of the list when Stream returned to Capitol Hill in April to rally support for H.R. 3667, a bill that would establish a pilot project to allow a portion of GME payments to go directly to community-based primary care residency programs. Those programs then would collaborate with local hospitals to provide necessary training in inpatient care.
By June, the Academy was asking members to contact their legislators to support a funding increase for Section 747 of Title VII of the Public Health Service Act, the only federal program that provides funds specifically to academic departments and programs to increase the number of primary care health professionals.
The AAFP also joined with the Council of Academic Family Medicine to call on Congress to spare GME funding in the deficit-reduction negotiations. However, if cuts cannot be alleviated, said the organizations, any reductions in Medicare GME "should be tailored in a manner that would allow for the advancement of primary care training."
2012: Year in Review
Pipeline, Changing Demographics Are Focus in 2012