The Nation's Physician Workforce Options for Balancing Supply and Requirements (1996) / Chapter Skim
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4 STRATEGIES FOR ADDRESSING PHYSICIAN SUPPLY ISSUES
4 STRATEGIES FOR ADDRESSING PHYSICIAN SUPPLY ISSUES
Pages 75-96
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From page 75... ...
The committee examined the likely effects of such high numbers in five areas: health care costs and expenditures, access to care, quality of care, appropriate use of human resources, and the future of academic health centers. The committee drew no firm conclusions about the net effects of these levels of physician supply, for two reasons.
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From page 76... ...
As shown later, the committee en toto did not embrace the two extreme positions (all market, all regulatory) , although some committee members voiced strong arguments in favor of a free market approach and others distinctly favored regulatory tactics.
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From page 77... ...
Furthermore, three imperfect markets may actually be operating: one is international and involves a global oversupply of physicians; one is national in scope and based on overall requirements for physician services; and the third is local and based more on hospitals' needs for inexpensive labor. One specific concern that the committee had about reliance solely on market forces is that this approach might thwart effective controls on the influx of graduates of foreign medical schools (i.e., international medical graduates, or IMGs)
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From page 78... ...
; establish a National Physician Workforce Commission; limit total funded residency slots to the number of 1993 U.S. medical school graduates plus 10 percent, and allocate this lower number of GME positions to "medical school coordinated consortia"; provide transition payments to hospitals most affected by the loss of resident physicians (e.g., the small number of IMG-dependent hospitals that deliver a disproportionate amount of care to the poor)
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From page 79... ...
All stringently restrict the entry of foreign-trained medical graduates.2 In effect, Canada has determined that its first responsibility "is to the sons and daughters of people who pay the medical education bill" (Harvey Barkun, Executive Director, Association of Canadian Medical Colleges, personal communication, September 19959. In addition, some provinces control specialist residency slots or limit the number of physicians eligible to be paid "full tariff' through the public health insurance plan, meaning that physicians cannot settle or practice any place they choose and still be reimbursed fully through usual government insurance procedures.
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From page 80... ...
reviewed the considerable obstacles that antitrust laws pose to many suggested solutions to physician workforce and supply issues. Problems arise, for example, in the following ways: (1 )
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From page 81... ...
Thus, it opted for a steady-state approach to undergraduate medical education. Specifically, the committee recommends that no new schools of allopathic or osteopathic medicine be opened, that class sizes in existing schools not be increased, and that public funds not be made available to open new schools or expand class size.
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From page 82... ...
" Third, closing medical schools or reducing class sizes might well undermine efforts to bring more minorities into the profession. It would fly in the face of the "3,000 by 2000" efforts of the Association of American Medical Colleges and of the recommendations of the Institute of Medicine (IOM)
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From page 83... ...
In keeping with the committee's principles as stated in Chapter 1 and its concerns about the growing number and proportion of IMGs in the nation's physician supply, the committee recommends that the federal government reform policies relating to the funding of graduate medical education, with the aim of bringing support for the total number of first-year residency slots much closer to the current number of graduates of U.S. medical schools.
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From page 84... ...
As cited above, for example, the seventh COGME report advocated that GME payments for residents who are graduates of foreign medical schools be much lower than for those who are graduates of U.S. medical schools.
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From page 85... ...
One way to accomplish this is to tie GME support to medical graduates directly rather than to send it solely to hospitals; put another way, current federal support for the graduate training of physicians could be uncoupled from payments that relate more to service demands on hospitals. Changes such as these would have the twin effects of making residency training slots less attractive financially to hospitals and, thereby, curbing the numbers of such positions.
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From page 86... ...
Given its time and resource constraints, the committee could not reach a considered opinion on the best way to effect its recommendation concerning reforms in GME funding. Rather, it believed that significant and immediate exploration of such a change (e.g., a voucher program and other options)
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From page 87... ...
do have an interest in continuing to provide graduate training experiences for foreign medical graduates. Such training brings individuals of many cultures and backgrounds together in ways that can have major beneficial effects on international understanding, communication, and cooperation.
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From page 88... ...
their presence in the practicing community here aggravates the mismatch between domestic physician supply and requirements. Of course, confining much of GME funding to USMGs, as recommended above, does not prevent teaching institutions from using IMG residents to any extent they choose.
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From page 89... ...
permit hospitals to hire nonphysician substitutes for IMG residents, such as physician assistants and advanced practice nurses;9 allow hospitals to hire or reimburse physicians in private practice to render some of the services now provided by IMG residents; facilitate the development of better and more extensive ambulatory care networks as a means of delivering outpatient care at sites other than large, inner-city hospitals; and increase opportunities for using physicians in the National Health Services Corps in this capacity. The committee did not examine these options in depth; neither did it explore alternative sources of such replacement funding, because that would have exceeded both its time and other resources and its basic charge.
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From page 90... ...
Specifically, the committee recommends that the Department of Health and Human Services, chiefly through the Health Resources and Services Administration, regularly make information on physician supply and requirements and the status of career opportunities in medicine available to policymakers, educators, professional associations, and the public. The committee further recommends that the American Medical Association, the Association of American Medical Colleges, the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and other professional associations cooperate with the federal government in widely disseminating such information to students indicating an interest in careers in medicine.
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From page 91... ...
In addition, COGME provides an important focus for generating topics for data collection, proposing workforce policies, and further publicizing information generated by the data collection and analysis efforts of BHP/HRSA. So, too, do the major physician associations and specialty societies; the committee, in taking specific note of the data collection efforts of the American Medical Association and the American Osteopathic Association, does not mean to imply that federal efforts ought to compete with, supersede, or replace these programs.
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From page 92... ...
Apart from government activity, the committee believes that the nation's major health foundations also can support the types of physician workforce research envisioned above. Several foundations have long traditions of interest in issues related to the health professions, including, for example, the Pew Charitable Trusts, the Robert Wood Johnson Foundation, and the Josiah Macy, Jr., Foundation.
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From page 93... ...
health care system; technological breakthroughs and the shifting balance between halfway technologies and the definitive interventions that will prevent or cure disease; the changes that may occur in the production of U.S. medical graduates; changes in the financing for graduate medical education; shifts in the rate of immigration and entry into practice of foreign medical graduates; and developments in the use of nonphysician health personnel.
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From page 94... ...
, the Canadian residency matching program deals nearly exclusively with graduates of LCME-accredited schools (i.e., those accredited by the Liaison Committee on Medical Education) and is run in two iterations, with only the residual second round open to graduates from non-LCMEaccredited schools; perhaps no more than 3 percent of all residents in Canada are foreign medical graduates.
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From page 95... ...
make clearer exactly what costs need to be underwritten, through public or private means, for adequate patient care; (b) enable USMGs to get residency training more suited to their likely practice locales in the future for instance, in areas that are presently medically underserved, in ambulatory settings, or in managed care systems; (c)
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From page 96... ...
In the study of nurse staffing in hospitals and nursing homes, the IOM committee (IOM, 1996, forthcoming) has looked into hospitals' use of different types of nursing staff, including advanced practice nurses, and discussed the types of leadership, management, and other training such personnel should receive to improve patient care and to reduce the incidence of workplace injury and stress.
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