Managed Care - February 2009 - (Page 33) areas with persistently inadequate numbers of primary care doctors, most regions are well within the range of adequate supply,” says Goodman. “In today’s physician labor market, more physicians means more specialists and higher costs with marginal benefits.” Robert Berenson, MD, a researcher at the Urban Institute, says that “there is no consensus about the extent of a shortage.” He adds that there is some agreement about a shortage of generalists, including general surgery, but there is no agreement on percent of medical schools indicated they have targeted enrollment increases to specific minority groups, underserved communities such as rural areas, or specialties such as primary care. The National Health Service Corps has provided incentives to primary care physicians to work in underserved areas. Since its creation, the NHSC consistently has received significantly more applications for positions than it is able to support, yet its funding has decreased by $47 million — 27 percent — since FY 2003, and former President Bush’s The primary issue when talking about the supply of physicians is the cap on Medicare funding of residency slots. the need for more medical students. “I think we need more studies to determine if there is an absolute shortage, and then we need to agree on the policy levers to deal with it, particularly shortages among generalists.” In response to the predicted shortage, the Association of American Medical Colleges (AAMC) has recommended a 30 percent increase in medical school enrollment by 2015. Its recent survey reported that 86 percent of medical schools have increased first-year enrollment or plan to do so. In addition, three new medical schools have received preliminary accreditation and 11 more are in the works. Enrollment is expected to increase by 21 percent, to 19,909, in 2012. The 30 percent goal would bring the total to 21,434. Enrollment at osteopathic medical colleges is rising faster. First year enrollment is projected to reach 5,227 in 2012, up 22 percent in five years. Medical school expansion is unfolding haphazardly. Berenson says there are no coordinated plans to address the distribution of doctors by specialty or geographically. The AAMC statement on the physician workforce says that “individual medical students and physicians should be free to determine for themselves which area of medicine they wish to pursue, and graduate medical education programs and teaching hospitals should be free to offer training” in whatever specialties they wish. COGME takes the position that the ratio of generalists to nongeneralists should reflect the actual demand for doctors in the marketplace. It has no numerical targets. The AAMC’s enrollment survey said that only 30 FY 2009 budget would reduce funding for the NHSC by another 2.4 percent from the FY 2008 omnibus appropriations. Limited funding has reduced new NHSC awards from 1,570 in FY 2003 to around 947 in FY 2008, down nearly 40 percent. Logjam The primary issue when talking about the supply of physicians is the cap on Medicare funding of residency slots. There has been a cap since 1997, and it will limit expansion of the physician workforce. Medical school expansion plans indicate there will be about 3,500 more allopathic and osteopathic graduates in 2012 than in 2002. The average residency lasts four years, so an additional 14,000 slots (one per doctor per year) will be required for these new graduates to complete their residencies. Thomas Nasca, MD, CEO of the Accreditation Council on Graduate Medical Education (ACGME), says that the number of residency slots increased only 1.4 percent between 2003 and 2008. The number of residents increased by 7.9 percent between 2002 and 2007, but Nasca says that was because there were fewer vacancies within the cap and there were slight increases in funding from other sources. Slots are also funded by Medicaid, some state budgets, the Veterans Health Administration, and hospitals themselves. Nasca says the average cost of a residency slot is over $100,000, considering faculty and other expenses, so the additional 14,000 slots would cost $1.4 billion. More money from Medicare is unlikely. “MedPAC is not considering recommending additional funding,” says Nasca. FEBRUARY 2009 / MANAGED CARE 33
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